<?php
require "connect_database.php";
session_start();
?>

<!DOCTYPE HTML>
<html>
    <head>
        <title>Mobile Insurance</title>
        <meta name="viewport" content="width=device-width, initial-scale=1">
        <link rel="stylesheet" href="http://code.jquery.com/mobile/1.2.1/jquery.mobile-1.2.1.min.css" />

        <script src="http://code.jquery.com/jquery-1.8.3.min.js"></script>
        <script src="http://code.jquery.com/mobile/1.2.1/jquery.mobile-1.2.1.min.js"></script>

        <script type="text/javascript">
        var $customer_title;
        var $gross_salary_applicant_1 = 0;
		var $overtime_applicant_1= 0;
		var $comission_bonus_applicant_1= 0;
		var $rental_income_applicant_1= 0;
		var $dividen_interest_applicant_1= 0;
		var $family_allowance_applicant_1= 0;
		var $motor_vehicle_allowance_applicant_1= 0;
		var $foreign_income_applicant_1= 0;
		var $other_income_income_applicant_1= 0;
		var $total_annual_income= 0;
        
			function onSuccess(data, status) {
				alert(data);
				//$.mobile.changePage( "#application_result_page", { transition: "slide"} );
				window.location.href = "#application_result_page";
			}

			function onError(data, status) {
				alert('error');
			}


			$(document).ready(function() {
				$("#loan_application_submit").click(function() {
					var formData = $("#loan_application_form").serialize();
					$.ajax({
						type : "POST",
						url : "personal_details_1st_process.php",
						data : formData,
						dataType : 'text',
						success : onSuccess,
						error : onError
					});
					return false;
				});
			});

			$('html').live('pageshow', function(event, ui) {
				var disable_option = 2;
				var $resident = $("#id_resident_of_australia");
				var $visa_type = $("#id_visa_type");
				var $resident_of = $("#id_resident_of");

				switch(disable_option) {
					case 1:
						$resident.change(function() {
							if ($resident.val() == "yes") {
								$visa_type.removeAttr('disabled');
								$resident_of.attr('disabled', 'disabled').val('');
							} else {
								$resident_of.removeAttr('disabled');
								$visa_type.attr('disabled', 'disabled').val('');
							}
						}).trigger('change');
						break;

					case 2:
						$resident.change(function() {
							if ($resident.val() == "yes") {
								$resident_of.addClass('ui-disabled');
								$visa_type.removeClass('ui-disabled');
							} else {
								$visa_type.addClass('ui-disabled');
								$resident_of.removeClass('ui-disabled');
							}
						}).trigger('change');
						break;
				}
			});

			$('html').live('pageshow', function(event, ui) {

				var $loan_purpose = $("#id_loan_purpose");
				var $specify_here = $("#id_specify_here");

				$loan_purpose.change(function() {
					if ($loan_purpose.val() == "others") {
						$specify_here.removeClass('ui-disabled');
					} else {
						$specify_here.addClass('ui-disabled');
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var $repayment_options = $("#id_repayment_options");
				var $interest_only_period = $("#id_interest_only_period");

				$repayment_options.change(function() {
					if ($repayment_options.val() == "interest_only") {
						$interest_only_period.removeClass('ui-disabled');
					} else {
						$interest_only_period.addClass('ui-disabled');
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var $loan_type = $("#id_loan_type");
				var $new_content = $("#id_new_content");
				var $vary_existing_loan_content = $("#id_vary_existing_loan_content");

				$loan_type.change(function() {
					if ($loan_type.val() == "new") {
						$new_content.show(200);
						$vary_existing_loan_content.hide();
					} else if ($loan_type.val() == "vary_existing_loan") {
						$new_content.hide();
						$vary_existing_loan_content.show(200);
					} else {
						$new_content.hide();
						$vary_existing_loan_content.hide();
						$("#id_loan_type option[value='blank']").hide();
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var $card_holder = $("#id_cardholder_different_with_proposer");
				var $card_holder_details = $("#id_card_holder_details");

				$card_holder.change(function() {
					if ($card_holder.val() == "yes") {
						$card_holder_details.hide(200);
					} else if ($card_holder.val() == "no") {
						$card_holder_details.show(200);
					} else {
						$card_holder_details.hide();
						$("#id_cardholder_different_with_proposer option[value='blank']").hide();
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var $campaign_type = $("#id_campaign_type_division");

				$("#id_financial_consultant_q2_span input[type=radio]").each(function(i) {
					$(this).click(function() {
						if (i == 0) {
							$campaign_type.show(200);
						} else {
							$campaign_type.hide(200);
						}
					});
				}).trigger('change');
			});

			//Loan application section6 onwards
			$('html').live('pageshow', function(event, ui) {
				var disable_option = 1;
				var disable_option2 = 1;
				var $numOfOtherRealEstate = $("#id_num_of_other_realestate");

				var $otherRealEstateAdd1Label = $("#id_other_real_estate_add1_label");
				var $otherRealEstateValueBalance1Label = $("#id_other_real_estate_value_balance1_label");

				var $otherRealEstateAdd1 = $("#id_other_real_estate_add1");
				var $otherRealEstateValueBalance1 = $("#id_other_real_estate_value_balance1");

				var $otherRealEstateAdd2Label = $("#id_other_real_estate_add2_label");
				var $otherRealEstateValueBalance2Label = $("#id_other_real_estate_value_balance2_label");

				var $otherRealEstateAdd2 = $("#id_other_real_estate_add2");
				var $otherRealEstateValueBalance2 = $("#id_other_real_estate_value_balance2");

				var $otherRealEstateAdd3Label = $("#id_other_real_estate_add3_label");
				var $otherRealEstateValueBalance3Label = $("#id_other_real_estate_value_balance3_label");

				var $otherRealEstateAdd3 = $("#id_other_real_estate_add3");
				var $otherRealEstateValueBalance3 = $("#id_other_real_estate_value_balance3");

				var $otherRealEstateAdd4Label = $("#id_other_real_estate_add4_label");
				var $otherRealEstateValueBalance4Label = $("#id_other_real_estate_value_balance4_label");

				var $otherRealEstateAdd4 = $("#id_other_real_estate_add4");
				var $otherRealEstateValueBalance4 = $("#id_other_real_estate_value_balance4");

				$numOfOtherRealEstate.change(function() {
					if ($numOfOtherRealEstate.val() == "0") {
						$("#id_other_real_estate_add1_overall").hide();
						$("#id_other_real_estate_add2_overall").hide();
						$("#id_other_real_estate_add3_overall").hide();
						$("#id_other_real_estate_add4_overall").hide();
					} else if ($numOfOtherRealEstate.val() == "1") {

						$("#id_other_real_estate_add1_overall").show();
						$("#id_other_real_estate_add2_overall").hide();
						$("#id_other_real_estate_add3_overall").hide();
						$("#id_other_real_estate_add4_overall").hide();

					} else if ($numOfOtherRealEstate.val() == "2") {
						$("#id_other_real_estate_add1_overall").show();
						$("#id_other_real_estate_add2_overall").show();
						$("#id_other_real_estate_add3_overall").hide();
						$("#id_other_real_estate_add4_overall").hide();

					} else if ($numOfOtherRealEstate.val() == "3") {
						$("#id_other_real_estate_add1_overall").show();
						$("#id_other_real_estate_add2_overall").show();
						$("#id_other_real_estate_add3_overall").show();
						$("#id_other_real_estate_add4_overall").hide();

					} else if ($numOfOtherRealEstate.val() == "4") {
						$("#id_other_real_estate_add1_overall").show();
						$("#id_other_real_estate_add2_overall").show();
						$("#id_other_real_estate_add3_overall").show();
						$("#id_other_real_estate_add4_overall").show();
					}
				}).trigger('change');

			});

			$('html').live('pageshow', function(event, ui) {

				var $numOfOtherPropertyLoan = $("#id_num_of_other_property_loan");

				$numOfOtherPropertyLoan.change(function() {

					if ($numOfOtherPropertyLoan.val() == "0") {

						$("#id_other_property_loan1_overall").hide();
						$("#id_other_property_loan2_overall").hide();
						$("#id_other_property_loan3_overall").hide();
						$("#id_other_property_loan4_overall").hide();

					} else if ($numOfOtherPropertyLoan.val() == "1") {
						$("#id_other_property_loan1_overall").show();
						$("#id_other_property_loan2_overall").hide();
						$("#id_other_property_loan3_overall").hide();
						$("#id_other_property_loan4_overall").hide();

					} else if ($numOfOtherPropertyLoan.val() == "2") {
						$("#id_other_property_loan1_overall").show();
						$("#id_other_property_loan2_overall").show();
						$("#id_other_property_loan3_overall").hide();
						$("#id_other_property_loan4_overall").hide();
					} else if ($numOfOtherPropertyLoan.val() == "3") {

						$("#id_other_property_loan1_overall").show();
						$("#id_other_property_loan2_overall").show();
						$("#id_other_property_loan3_overall").show();
						$("#id_other_property_loan4_overall").hide();

					} else if ($numOfOtherPropertyLoan.val() == "4") {

						$("#id_other_property_loan1_overall").show();
						$("#id_other_property_loan2_overall").show();
						$("#id_other_property_loan3_overall").show();
						$("#id_other_property_loan4_overall").show();

					}
				}).trigger('change');

			});

			$('html').live('pageshow', function(event, ui) {

				var typeOfProperty1 = $("#id_type_of_property1");
				typeOfProperty1.change(function() {
					if (typeOfProperty1.val() == "house") {
						$("#id_div_if_flat1").show();
						$("#id_if_flat_unit1").prop("disabled", false);
						$("#id_div_if_studio1").hide();
						$("#id_if_studio1").prop("disabled", true);
					} else if (typeOfProperty1.val() == "studio") {
						$("#id_div_if_flat1").hide();
						$("#id_if_flat_unit1").prop("disabled", true);
						$("#id_div_if_studio1").show();
						$("#id_if_studio1").prop("disabled", false);
					} else {

						$("#id_div_if_studio1").hide();
						$("#id_if_studio1").prop("disabled", true);
						$("#id_div_if_flat1").hide();
						$("#id_if_flat_unit1").prop("disabled", true);
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var typeOfProperty2 = $("#id_type_of_property2");
				typeOfProperty2.change(function() {
					if (typeOfProperty2.val() == "house") {
						$("#id_div_if_flat2").show();
						$("#id_if_flat_unit2").prop("disabled", false);
						$("#id_div_if_studio2").hide();
						$("#id_if_studio2").prop("disabled", true);
					} else if (typeOfProperty2.val() == "studio") {
						$("#id_div_if_flat2").hide();
						$("#id_if_flat_unit2").prop("disabled", true);
						$("#id_div_if_studio2").show();
						$("#id_if_studio2").prop("disabled", false);
					} else {

						$("#id_div_if_studio2").hide();
						$("#id_div_if_flat2").hide();
						$("#id_if_flat_unit2").prop("disabled", true);
						$("#id_if_studio2").prop("disabled", true);
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var depositUnderLien = $("#id_deposit_under_lien");
				depositUnderLien.change(function() {
					if (depositUnderLien.val() == "yes") {
						$("#id_div_deposit_under_lien").show();

					} else {
						$("#id_div_deposit_under_lien").hide();

						$("#id_deposit_under_lien_amount").val("");
						$("#id_deposit_under_lien_acc").val("");
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var feePaymentType = $("#id_payment_type");
				feePaymentType.change(function() {
					if (feePaymentType.val() == "debit_my_HSBC") {
						$("#id_HSBC_bank_acc").show();

					} else {
						$("#id_HSBC_bank_acc").hide();

						$("#id_HSBC_account_num").val("");
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var quotationType = $("#id_insurance_quotation");
				quotationType.change(function() {
					if (quotationType.val() == "yes") {
						$("#id_quotation_yes").show();

					} else {
						$("#id_quotation_yes").hide();

						$("#id_quotation_yes").val("");
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {

				var assistLifeMortgageInsurance = $("#id_assist_life_mortage_insurance");
				assistLifeMortgageInsurance.change(function() {
					if (assistLifeMortgageInsurance.val() == "yes") {
						$("#id_assist_life_mortage_insurance_type_layout").show();

					} else {
						$("#id_assist_life_mortage_insurance_type_layout").hide();

						$("#id_assist_life_mortage_insurance_type_layout").val("");
					}
				}).trigger('change');
			});

			$('html').live('pageshow', function(event, ui) {
				var disable_option = 2;
				var $smoke_qus = $("#id_smoke_qus");
				var $smoking_content = $("#id_smoking_content");
				var $smokeed_years = $("#")

				$smoke_qus.change(function() {

					if ($smoke_qus.val() == "yes") {
						$smoking_content.show();
						

					} else {
						$smoking_content.hide();
						

					}

				}).trigger('change');

			});

			$('html').live('pageshow', function(event, ui) {

				var $nationality = $("#id_insurance_nationality");
				var $citizen = $("#id_citizen");
				var $PR = $("#id_PR");
				var $others = $("#id_others");

				$nationality.change(function() {

					if ($nationality.val() == "Singapore Citizen") {
						$citizen.show();
						$PR.hide();
						$others.hide();
					} else if ($nationality.val() == "others") {
						$citizen.hide();
						$PR.hide();
						$others.show();

					} else if ($nationality.val() == "Singapore Permanent Resident") {
						$citizen.hide();
						$PR.show();
						$others.hide();
					}

				}).trigger('change');

			});
			
			$('html').live('pageshow', function(event, ui) {
				
				$()

			});
			
			$(document).ready(function() {
   				$('#id_question_14_yes').click(function(){
      				if ($('#id_question_14_yes').is(':checked')){
      					
      					$('#id_no_14_details').show();
      					$('#id_no_14_details_tb').show();
      				}
      			});
      			
      			$('#id_question_14_no').click(function(){
      				if ($('#id_question_14_no').is(':checked'))
      				{	
      					$('#id_no_14_details').hide();
      					$('#id_no_14_details_tb').hide();
      					$('#id_no_14_details_tb').val("");
      				}
   				});
   				
   				$('#id_country_city_q1_yes').click(function(){
      				if ($('#id_country_city_q1_yes').is(':checked')){
      					
      					$('#id_travel_purpose_label').show();
      					$('#id_travel_purpose_tb').show();
      				}
      			});
      			
      			$('#id_country_city_q1_no').click(function(){
      				if ($('#id_country_city_q1_no').is(':checked'))
      				{	
      					$('#id_travel_purpose_label').hide();
      					$('#id_travel_purpose_tb').hide();
      					$('#id_travel_purpose_tb').val("");
      				}
   				});
   				
   				$('#id_country_city_q2_yes').click(function(){
      				if ($('#id_country_city_q2_yes').is(':checked')){
      					
      					$('#id_country_city_q2_yes_label').show();
      					$('#id_country_city_q2_yes_tb').show();
      				}
      			});
      			
      			$('#id_country_city_q2_no').click(function(){
      				if ($('#id_country_city_q2_no').is(':checked'))
      				{	
      					$('#id_country_city_q2_yes_label').hide();
      					$('#id_country_city_q2_yes_tb').hide();
      					$('#id_country_city_q2_yes_tb').val("");
      				}
   				});
   				
   				$('#id_travel_q1_yes').click(function(){
      				if ($('#id_travel_q1_yes').is(':checked')){
      					
      					$('#id_name_of_country_label').show();
      					$('#id_name_of_country_tb').show();
      					$('#id_stay_duration_label').show();
      					$('#id_stay_duration_tb').show();
      					$('#id_travel_purpose_12mth_label').show();
						$('#id_travel_purpose_12mth_tb').show();
      					
      				}
      			});
      			
      			$('#id_travel_q1_no').click(function(){
      				if ($('#id_travel_q1_no').is(':checked'))
      				{	
      					$('#id_name_of_country_label').hide();
      					$('#id_name_of_country_tb').hide();
      					$('#id_name_of_country_tb').val("");
      					$('#id_stay_duration_label').hide();
      					$('#id_stay_duration_tb').hide();
      					$('#id_stay_duration_tb').val("");
      					$('#id_travel_purpose_12mth_label').hide();
						$('#id_travel_purpose_12mth_tb').hide();
						$('#id_travel_purpose_12mth_tb').val("");
      				}
   				});
   				
   				$('#id_question_1c_yes').click(function(){
      				if ($('#id_question_1c_yes').is(':checked')){
      					
      					$('#id_question_1c_give_details_label').show();
      					$('#id_question_1c_give_details_ta').show();
      				}
      			});
      			
      			$('#id_question_1c_no').click(function(){
      				if ($('#id_question_1c_no').is(':checked'))
      				{	
      					$('#id_question_1c_give_details_label').hide();
      					$('#id_question_1c_give_details_ta').hide();
      					$('#id_question_1c_give_details_ta').val("");
      				}
   				});
   				
   				$('#id_question_9_yes').click(function(){
      				if ($('#id_question_9_yes').is(':checked')){
      					
      					$('#id_question_9_details_1_if_yes_label').show();
      					$('#id_question_9_details_1_label').show();
      					$('#id_question_9_details_1_tb').show();
      					$('#id_question_9_details_2_label').show();
      					$('#id_question_9_details_2_tb').show();
      					$('#id_question_9_details_3_label').show();
      					$('#id_question_9_details_3_tb').show();
      					$('#id_question_9_details_4_label').show();
      					$('#id_question_9_details_4_tb').show();
      					$('#id_question_9_details_5_label').show();
      					$('#id_question_9_details_5_tb').show();
      				}
      			});
      			
      			$('#id_question_9_no').click(function(){
      				if ($('#id_question_9_no').is(':checked'))
      				{	
      					$('#id_question_9_details_1_if_yes_label').hide();
      					$('#id_question_9_details_1_label').hide();
      					$('#id_question_9_details_1_tb').hide();
      					$('#id_question_9_details_1_tb').val("");
      					$('#id_question_9_details_2_label').hide();
      					$('#id_question_9_details_2_tb').hide();
      					$('#id_question_9_details_2_tb').val("");
      					$('#id_question_9_details_3_label').hide();
      					$('#id_question_9_details_3_tb').hide();
      					$('#id_question_9_details_3_tb').val("");
      					$('#id_question_9_details_4_label').hide();
      					$('#id_question_9_details_4_tb').hide();
      					$('#id_question_9_details_4_tb').val("");
      					$('#id_question_9_details_5_label').hide();
      					$('#id_question_9_details_5_tb').hide();
      					$('#id_question_9_details_5_tb').val("");
      				}
   				});
   				
   				$('#id_question_15_yes').click(function(){
      				if ($('#id_question_15_yes').is(':checked')){
      					
      					$('#id_14details_label').show();
      					$('#id_14details_1_label').show();
      					$('#id_14details_1_tb').show();
      					$('#id_14details_2_label').show();
      					$('#id_14details_2_tb').show();
      					$('#id_14details_3_label').show();
      					$('#id_14details_3_tb').show();
      					$('#id_14details_4_label').show();
      					$('#id_14details_4_tb').show();
      				}
      			});
      			
      			$('#id_question_15_no').click(function(){
      				if ($('#id_question_15_no').is(':checked'))
      				{	
      					$('#id_14details_label').hide();
      					$('#id_14details_1_label').hide();
      					$('#id_14details_1_tb').hide();
      					$('#id_14details_1_tb').val("");
      					$('#id_14details_2_label').hide();
      					$('#id_14details_2_tb').hide();
      					$('#id_14details_2_tb').val("");
      					$('#id_14details_3_label').hide();
      					$('#id_14details_3_tb').hide();
      					$('#id_14details_3_tb').val("");
      					$('#id_14details_4_label').hide();
      					$('#id_14details_4_tb').hide();
      					$('#id_14details_4_tb').val("");
      				}
   				});
   				
   				$('#id_question_16_yes').click(function(){
      				if ($('#id_question_16_yes').is(':checked')){
      					
      					$('#id_16details_2_label').show();
      					$('#id_16details_2_tb').show();
      					$('#id_16details_3_label').show();
      					$('#id_16details_3_tb').show();
      					$('#id_16details_4_label').show();
      					$('#id_16details_4_tb').show();
      				}
      			});
      			
      			$('#id_question_16_no').click(function(){
      				if ($('#id_question_16_no').is(':checked'))
      				{	
      					$('#id_16details_2_label').hide();
      					$('#id_16details_2_tb').hide();
      					$('#id_16details_2_tb').val("");
      					$('#id_16details_3_label').hide();
      					$('#id_16details_3_tb').hide();
      					$('#id_16details_3_tb').val("");
      					$('#id_16details_4_label').hide();
      					$('#id_16details_4_tb').hide();
      					$('#id_16details_4_tb').val("");
      				}
   				});
   			
   			//Get data from page 1 of loan application
   			$('#personal_details_next_btn').click(function(){
					$customer_title = $("#id_title").val();
					$customer_surName = $("#id_surname").val();
					$customer_givenName = $('#id_givenname').val();
					$customer_gender = $("#id_gender").val();
					$customer_dob = $("#id_dob").val();
					$customer_citizen = $("#id_singapore_citizen").val();
					$customer_current_address=$("#id_current_residential_address").val();
					$customer_current_address_postcode = $("#id_current_residential_address_postcode").val();
					$customer_current_residential_year = $("#id_current_residential_year").val();
					$customer_current_residential_month = $("#id_current_residential_month").val();
					$customer_postal_address = $("#id_postal_address").val();
					$customer_postal_address_postcode = $("#id_postal_address_postcode").val();
					$customer_email = $("#id_email_address").val();
					$customer_mobile = $("#id_mobile_phone_number").val();
					$customer_mobile_countrycode = $("#id_mobile_phone_number_ext").val();
					
					validate();

					//console.log("title " + $customer_title);
					console.log("$customer_citizen " + $customer_citizen);
				});
   				
		
			
			$('#employment_details').click(function(){
					$customer_occupation = $("#id_current_occupation").val();
					$customer_occupation_status = $("#id_employment_status").val();
					$customer_occupation_level = $('#id_employment_level').val();
					$customer_employer_name = $('#id_employer_name').val();
					
					//console.log("title " + $customer_title);
					//console.log("customer dob " + $customer_dob);
				});
				
			$('#insurance_page_2').click(function(){
			
				$insurance_payment_method = $("#id_payment_method").val();
				console.log("payment method " + $insurance_payment_method);
				
				});
				
				$('#monthly_gross_income').click(function(){
			
				$gross_salary_applicant_1 = $("#id_gross_salary_applicant_1").val();
				var $gross_salary_applicant_1_int = parseInt($gross_salary_applicant_1);
				
				$overtime_applicant_1 = $("#id_overtime_applicant_1").val();
				var $overtime_applicant_1_int = parseInt($overtime_applicant_1);
				
				$comission_bonus_applicant_1 = $("#id_comission_bonus_applicant_1").val();
				var $comission_bonus_applicant_1_int = parseInt($comission_bonus_applicant_1);
				
				$rental_income_applicant_1 = $("#id_rental_income_applicant_1").val();
				var $rental_income_applicant_1_int = parseInt($rental_income_applicant_1);
				
				$dividen_interest_applicant_1 = $("#dividend_interest_income_applicant_1").val();
				var $dividen_interest_applicant_1_int = parseInt($dividen_interest_applicant_1);
				
				$family_allowance_applicant_1 = $("#family_allowance_income_applicant_1").val();
				var $family_allowance_applicant_1_int = parseInt($family_allowance_applicant_1);
				
				$motor_vehicle_allowance_applicant_1 = $("#motor_vehicle_allowance_applicant_1").val();
				var $motor_vehicle_allowance_applicant_1_int = parseInt($motor_vehicle_allowance_applicant_1);
				
				$foreign_income_applicant_1 = $("#foreign_income_applicant_1").val();
				var $foreign_income_applicant_1_int = parseInt($foreign_income_applicant_1);
				
				$other_income_income_applicant_1 = $("#other_income_applicant_1").val();
				var $other_income_income_applicant_1_int = parseInt($other_income_income_applicant_1);
				
				$total_annual_income = ($gross_salary_applicant_1_int + $overtime_applicant_1_int + $comission_bonus_applicant_1_int + 
										$rental_income_applicant_1_int + $dividen_interest_applicant_1_int + $family_allowance_applicant_1_int
										+ $motor_vehicle_allowance_applicant_1_int + $foreign_income_applicant_1_int + $other_income_income_applicant_1_int) * 12;
				
				
				});
				
				
   				
			});
			
			
			//transfer data to page to of insurance application
			$(document).on('pageinit', '#insurance_personal_details', function(){
				$('input[id=id_insurance_title]').val($customer_title);
				$('input[id=id_insurance_title]').textinput('disable');
				$('input[id=id_insurance_surname]').val($customer_surName);
				$('input[id=id_insurance_surname]').textinput('disable');
				$('input[id=id_insurance_givenname]').val($customer_givenName);
				$('input[id=id_insurance_givenname]').textinput('disable');
				$('input[id=id_insurance_dob]').val($customer_dob);
				$('input[id=id_insurance_dob]').textinput('disable');
				$('input[id=id_insurance_occupation]').val($customer_occupation);
				$('input[id=id_insurance_occupation]').textinput('disable');
				$('input[id=id_Precise_Occupation]').val($customer_occupation_status+" "+$customer_occupation+" ("+$customer_occupation_level+")");
				$('input[id=id_Precise_Occupation]').textinput('disable');
				$('input[id=id_Name_of_employer]').val($customer_employer_name);
				$('input[id=id_Name_of_employer]').textinput('disable');
				$('input[id=id_Annual_Income]').val($total_annual_income);
				$('input[id=id_Annual_Income]').textinput('disable');
				
				if($customer_gender == "Male"){
					$("#id_insurance_gender").val("Male");
				}
				else{
					$("#id_insurance_gender").val("Female");
				}
				
				//refresh and force rebuild
				$('#id_insurance_gender').selectmenu('refresh', true);
				
							
				//enable: enable a disabled select.
				
				$('#id_insurance_gender').selectmenu('disable');
				
				
				if($customer_citizen == "singaporean"){
					$("#id_insurance_nationality").val("Singapore Citizen");
				}
				else if($customer_citizen == "Singapore Permanent Resident"){
					$("#id_insurance_nationality").val("Singapore Permanent Resident");
				}
				
				else if($customer_citizen == "others"){
					$("#id_insurance_nationality").val("others");
				}
				
				
				//refresh and force rebuild
				$('#id_insurance_nationality').selectmenu('refresh', true);
				
							
				//enable: enable a disabled select.
				
				$('#id_insurance_nationality').selectmenu('disable');
			
				console.log("id_insurance_nationality title " + $customer_citizen);
			});
			
			$(document).on('pageinit', '#insurance_page_2', function(){
			
			$('input[id=id_insurance_address_residential]').val($customer_current_address + " S(" +$customer_current_address_postcode+")");
			$('input[id=id_insurance_address_residential]').textinput('disable');
			
			$('input[id=id_insurance_mailing_address]').val($customer_postal_address + " S(" +$customer_postal_address_postcode+")");
			$('input[id=id_insurance_mailing_address]').textinput('disable');
			
			$('input[id=id_insurance_email]').val($customer_email);
			$('input[id=id_insurance_email]').textinput('disable');
			
			$('input[id=id_mobile_phone]').val("("+$customer_mobile_countrycode + ") " +$customer_mobile);
			$('input[id=id_mobile_phone]').textinput('disable');
			
			
			
			});
			
			
			
			$(document).on('pageinit', '#details_of_credit_card_payment', function(){
				
				if($insurance_payment_method == "Credit Card"){
				
         		$.mobile.changePage("http://chandrajcu.webfactional.com/jcumfidatabase/personal_details.php#details_of_credit_card_payment");
				
				}
				
				else{
					
					$.mobile.changePage("http://chandrajcu.webfactional.com/jcumfidatabase/personal_details.php#important_notes");
				}
			});
			
			function validate()
					{
					 
					   if($customer_title == "" )
					   {
					   	 console.log("title empty");
					     alert( "Please provide your name!" );
					     $("#id_title").focus() ;
					     return false;
					}
				}

        </script>

    </head>

    <body>

        <form id="loan_application_form" name="myForm">

            <div data-role="page">

                <div data-role="header">
                    <h1>Personal Details</h1>
                </div>

                <div id="personal_details" data-role="content">

                    <div data-role="fieldcontain">
                        <label for="applicant_type" class="ui-input-text">Type Of Applicant:</label>
                        <select name="applicant_type" id="id_applicant_type">
                            <option value="borrower">Borrower</option>
                            <option value="guarantor">Guarantor</option>
                            <option value="director">Director</option>
                            <option value="trustee">Trustee</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="title" class="ui-input-text">Title:</label>
                        <input type="text" name="title" id="id_title" pattern="[0-9]{10}" required="required" oninvalid="setCustomValidity('Plz enter on Alphabets ')"
    						onchange="try{setCustomValidity('')}catch(e){}" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="surname" class="ui-input-text">Surname:</label>
                        <input type="text" name="surname" id="id_surname" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="givenname" class="ui-input-text">Given Name(s):</label>
                        <input type="text" name="givenname" id="id_givenname" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="gender" class="ui-input-text">Gender:</label>
                        <select name="gender" id="id_gender">
                            <option value="Male">Male</option>
                            <option value="Female">Female</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="dob" class="ui-input-text" id="id_dob_label">Date Of Birth: </label>
                        <input id="id_dob" type="date" name="dob">
                    </div>

                    <label for="fax_number" class="ui-input-text">Fax Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="fax_number_ext" id="id_fax_number_ext" placeholder="country code" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="fax_number" id="id_fax_number" placeholder="fax number" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <label for="home_phone_number" class="ui-input-text">Home Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="home_phone_number_ext" id="id_home_phone_number_ext" placeholder="country code" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="home_phone_number" id="id_home_phone_number" placeholder="Home Phone Number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <label for="work_phone_number" class="ui-input-text">Work Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="work_phone_number_ext" id="id_work_phone_number_ext" placeholder="country code" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="work_phone_number" id="id_work_phone_number" placeholder="Work Phone Number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <label for="mobile_phone_number" class="ui-input-text">Mobile Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="mobile_phone_number_ext" id="id_mobile_phone_number_ext" placeholder="country code" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="mobile_phone_number" id="id_mobile_phone_number" placeholder="Mobile Phone Number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="email_address" class="ui-input-text">Email Address:</label>
                        <input type="text" name="email_address" id="id_email_address" placeholder="Emaill Address" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="martial_status" class="ui-input-text">Martial Status:</label>
                        <select name="martial_status" id="id_martial_status">
                            <option value="single">Single</option>
                            <option value="married">Married</option>
                            <option value="separated">Separated</option>
                            <option value="divorced">Divorced</option>
                            <option value="defacto">Defacto</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="residential_status" class="ui-input-text">Residential Status:</label>
                        <select name="residential_status" id="id_residential_status">
                            <option value="married">Married</option>
                            <option value="mortgaged" selected>Own Home Mortgaged</option>
                            <option value="boarding">Boarding</option>
                            <option value="renting">Renting</option>
                            <option value="livewithparent">Live With Parent</option>
                            <option value="other">Other</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="singapore_citizen" class="ui-input-text">Singapore Citizen:</label>
                        <select name="nationality" id="id_singapore_citizen">
                            <option value="singaporean">Yes</option>
                            <option value="Singapore Permanent Resident">Singapore Permanent Resident/Employment Pass/Work Permit</option>
						    <option value="others">Others (eg. Dependant Pass/Long Term Visit Pass/Student Pass/Social Visit Pass, etc.)</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="resident_of_singapore" class="ui-input-text">Resident of Singapore:</label>
                        <select name="resident_of_singapore" id="id_resident_of_singapore">
                            <option value="Yes">Yes</option>
                            <option value="No">No</option>
                        </select>
                    </div>

                   <!-- 
                   	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="visa_type" class="ui-input-text">Type of Visa:</label>
                        <input type="text" name="visa_type" id="id_visa_type" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                   </div>
                   -->

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="country" class="ui-input-text">Resident of:</label>
                        <input type="text" name="resident_of" id="id_resident_of" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <label for="current_residential" class="ui-input-text"><strong>Current Residential</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="current_residential_address" class="ui-input-text">Address:</label>
                        <textarea name="current_residential_address" id="id_current_residential_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="current_residential_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="current_residential_address_postcode" id="id_current_residential_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <div data-role="fieldcontain">
                        <fieldset data-role="controlgroup" data-type="horizontal">
                            <legend>
                                Time With Current Residential:
                            </legend>

                            <select name="current_residential_year" id="id_current_residential_year">
                                <option>Year</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                            <select name="current_residential_month" id="id_current_residential_month">
                                <option>Month</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                        </fieldset>
                    </div>

                    <label for="current_residential" class="ui-input-text"><strong>Postal Address (complete only if different to residential address)</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="postal_address" class="ui-input-text">Address:</label>
                        <textarea name="postal_address" id="id_postal_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="postal_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="postal_address_postcode" id="id_postal_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <label for="after_loan_postal" class="ui-input-text"><strong>After Loan Postal Residential</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="after_loan_postal_address" class="ui-input-text">Address:</label>
                        <textarea name="after_loan_postal_address" id="id_after_loan_postal_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="after_loan_postal_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="after_loan_postal_address_postcode" id="id_after_loan_postal_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <label for="previous_residential" class="ui-input-text"><strong>Previous Residential</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="previous_residential_address" class="ui-input-text">Address:</label>
                        <textarea name="previous_residential_address" id="id_previous_residential_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="previous_residential_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="previous_residential_address_postcode" id="id_previous_residential_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <div data-role="fieldcontain">
                        <fieldset data-role="controlgroup" data-type="horizontal">
                            <legend>
                                Time With Previous Residential:
                            </legend>

                            <select name="previous_residential_year" id="id_previous_residential_year">
                                <option>Year</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                            <select name="previous_residential_month" id="id_previous_residential_month">
                                <option>Month</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                        </fieldset>
                    </div>

                    <label for="Driver Licence Details" class="ui-input-text"><strong>Driver Licence Details</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="licence_number" class="ui-input-text">Number:</label>
                        <input type="text" name="licence_number" id="id_licence_number" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="licence_state" class="ui-input-text">State:</label>
                        <input type="text" name="licence_state" id="id_licence_state" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="licence_expiry_date" class="ui-input-text" id="id_licence_expiry_date">Expiry Date: </label>
                        <input id="id_licence_expiry_date" type="date" name="licence_expiry_date">
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <!--	<div class="ui-block-b"><button type="submit" id="form_submit_button" data-theme="b">Submit</button><div> -->
                        <div class="ui-block-b">
                            <a  data-role="button" data-theme="b" data-transition="fade" id="personal_details_next_btn">Next</a>
                        </div>
                    </fieldset>

                </div>

            </div>
			</div>
			</div>

            <div data-role="page" id="employment_details">

                <div data-role="header">
                    <h1>Employment Details</h1>
                </div>

                <div data-role="content">

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="current_occupation" class="ui-input-text">Current Occupation:</label>
                        <input type="text" name="current_occupation" id="id_current_occupation" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="employment_level" class="ui-input-text">Employment Level:</label>
                        <select name="employment_level" id="id_employment_level">
                            <option value="director">Director</option>
                            <option value="manager">Manager</option>
                            <option value="executive">Executive</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="employment_status" class="ui-input-text">Employment Status:</label>
                        <select name="employment_status" id="id_employment_status">
                            <option value="fulltime">Full-Time</option>
                            <option value="partime">Part-Time</option>
                            <option value="casual">Casual</option>
                            <option value="contractor">Contractor</option>
                            <option value="self_employed">Self-Employed</option>
                            <option value="not-employed">Not-Employed</option>
                        </select>
                    </div>

                    <label for="current_employer_details" class="ui-input-text"><strong>Current Employer Details</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="employer_name" class="ui-input-text">Name:</label>
                        <input type="text" name="employer_name" id="id_employer_name" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <label for="employer_phone_number" class="ui-input-text">Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="employer_phone_number_ext" id="id_employer_phone_number_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="employer_phone_number" id="id_employer_phone_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <label for="employer_fax_number" class="ui-input-text">Fax Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="employer_fax_number_ext" id="id_employer_fax_number_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="employer_fax_number" id="id_employer_fax_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="employer_address" class="ui-input-text">Address:</label>
                        <textarea name="employer_address" id="id_employer_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="employer_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="employer_address_postcode" id="id_employer_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <div data-role="fieldcontain">
                        <fieldset data-role="controlgroup" data-type="horizontal">
                            <legend>
                                Time With Current Employer:
                            </legend>

                            <select name="current_employer_year" id="id_current_employer_year">
                                <option>Year</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                            <select name="current_employer_month" id="id_current_employer_month">
                                <option>Month</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                        </fieldset>
                    </div>

                    <label for="current_employer_details" class="ui-input-text"><strong>Previous Employer Details</strong></label>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="previous_employer_name" class="ui-input-text">Name:</label>
                        <input type="text" name="previous_employer_name" id="id_previous_employer_name" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <label for="previous_employer_phone_number" class="ui-input-text">Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="previous_employer_phone_number_ext" id="id_previous_employer_phone_number_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="previous_employer_phone_number" id="id_previous_employer_phone_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="previous_employer_address" class="ui-input-text">Address:</label>
                        <textarea name="textarea" id="id_previous_employer_address"></textarea>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="previous_employer_address_postcode" class="ui-input-text">Post Code:</label>
                        <input type="text" name="previous_employer_address_postcode" id="id_previous_employer_address_postcode" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:15%">
                    </div>

                    <div data-role="fieldcontain">
                        <fieldset data-role="controlgroup" data-type="horizontal">
                            <legend>
                                Time With Previous Employer:
                            </legend>

                            <select name="previous_employer_year" id="id_previous_employer_year">
                                <option>Year</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                            <select name="previous_employer_month" id="id_previous_employer_moneth">
                                <option>Month</option>
                                <option value="1">1</option>
                                <option value="2">2</option>
                            </select>

                        </fieldset>
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#loan_structure_and_purpose" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                         <div class="ui-block-b">
                            <a href="#insurance_personal_details" data-role="button" data-theme="b" data-transition="fade" id="personal_details_next_btn">insurance personal</a>
                        </div>
                    </fieldset>

                </div>

            </div>

            <div data-role="page" id="loan_structure_and_purpose">

                <div data-role="header">
                    <h1>Loan Structure & Purpose</h1>
                </div>

                <div data-role="content">

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="total_loan_amount" class="ui-input-text">Total Loan Amount:</label>
                        <input type="text" name="total_loan_amount" id="id_total_loan_amount" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="loan_type" class="ui-input-text">Loan Type:</label>
                        <select name="loan_type" id="id_loan_type">
                            <option value="blank"></option>
                            <option value="new">New</option>
                            <option value="vary_existing_loan">Vary Existing Loan</option>
                        </select>
                    </div>

                    <div id = "id_new_content">

                        <div data-role="fieldcontain">
                            <label for="loan_purpose" class="ui-input-text">Loan Purpose:</label>
                            <select name="loan_purpose" id="id_loan_purpose">
                                <option value="purchase_property">Purchase Property</option>
                                <option value="refinance_property">Refinance Property</option>
                                <option value="others">Others</option>
                            </select>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="specify_here" class="ui-input-text">Specify Here:</label>
                            <input type="text" name="specify_here" id="id_specify_here" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <div data-role="fieldcontain">
                            <fieldset data-role="controlgroup" data-type="horizontal">

                                <legend>
                                    Loan Reason:
                                </legend>

                                <select name="loan_reason" id="id_loan_reason">
                                    <option value="personal">Personal</option>
                                    <option value="invest">Invest</option>
                                </select>

                            </fieldset>
                        </div>

                        <div data-role="fieldcontain">
                            <fieldset data-role="controlgroup" data-type="horizontal">

                                <legend>
                                    Loan Term:
                                </legend>

                                <select name="loan_term" id="id_loan_term">
                                    <option>Year</option>
                                    <option value="1">1</option>
                                    <option value="2">2</option>
                                </select>

                            </fieldset>
                        </div>

                        <div data-role="fieldcontain">
                            <fieldset data-role="controlgroup" data-type="horizontal">

                                <legend>
                                    Repayment Options:
                                </legend>

                                <select name="repayment_options" id="id_repayment_options">
                                    <option value="principle_interest">Principle Interest</option>
                                    <option value="interest_only">Interest Only Period (Years)</option>
                                </select>

                            </fieldset>
                        </div>

                        <div data-role="fieldcontain">
                            <fieldset data-role="controlgroup" data-type="horizontal">

                                <legend>
                                    Interest Only Period (Years):
                                </legend>

                                <select name="interest_only_period" id="id_interest_only_period">
                                    <option>Year</option>
                                    <option value="1">1</option>
                                    <option value="2">2</option>
                                    <option value="3">3</option>
                                </select>

                            </fieldset>
                        </div>

                    </div>

                    <div id="id_vary_existing_loan_content">

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="account_number_to_be_varied" class="ui-input-text">Account Number To Be Varied:</label>
                            <input type="text" name="account_number_to_be_varied" id="id_account_number_to_be_varied" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="loan_limit_change" class="ui-input-text">Change To Limit:</label>
                            <input type="text" name="loan_limit_change" id="id_loan_limit_change" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#id_asset" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                    </fieldset>

                </div>

            </div>

            <div data-role="page" id="id_asset">

                <!--div for application header-->
                <div data-role="header">
                    <h1>Assets (What you own)</h1>
                </div>

                <div data-role="content">

                    <!--div for important note-->
                    <div id="section_6_important_notes">
                        <p>
                            - Please specify Combined assets and liabilities for JOINT APPLICANTS
                        </p>
                        <p>
                            - Photocopy this page if you wish to make SEPARATE assets and liabilities statements
                        </p>
                        <p>
                            - ALL Guarantors must provide a statments of assets and liabilities</br></br>
                        </p>
                    </div>

                    <!--div for form home address-->

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="cash_deposits_label" class="ui-input-text" id="cash_ceposits_label">Cash deposits:</label>
                        <input type="text" name="cashdeposits"  id="id_cash_deposits" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="shares_label" class="ui-input-text" id="shares_label">shares:</label>
                        <input type="text" name="shares"  id="id_shares" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="motor_vehicles_label" class="ui-input-text" id="motor_vehicles_label">Motor vehicles:</label>
                        <input type="text" name="motorvehicles"  id="id_motor_vehicles" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="furniture_label" class="ui-input-text" id="furniture_label">furniture (insured value):</label>
                        <input type="text" name="furniture"  id="id_furniture" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_assets_label" class="ui-input-text" id="other_assets_label">Other assets:</label>
                        <input type="text" name="other_assets"  id="id_other_assets" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="superannuation/lifeinsurance_label" class="ui-input-text" id="superannution_lifeinsurance_label">Superannuation/Life insurance:</label>
                        <input type="text" name="superannuation_lifeinsurance"  id="id_superannution_lifeinsurance" placeholder="value/Balance"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="total_assets" class="ui-input-text" id="total_assets">Total value/balance:</label>
                        <label for="cal_total_assets" name="calculated_total_assets" class="ui-input-text" id="cal_total_assets">calulated Total</label>
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#Liabilities" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                    </fieldset>

                </div>
            </div>

            <div data-role="page" id="Liabilities">

                <div data-role="header">
                    <h1>Liabilities (What you owe)</h1>
                </div>

                <div data-role="content">

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="home_loan_label" name="home_loan_label" class="ui-input-text" id="home_loan_label"><strong>Home loan</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="home_loan_lender_label" class="ui-input-text" id="home_loan_lender_label">Lender:</label>
                        <input type="text" name="home_loan_lender_name"  id="id_home_loan_lender" placeholder="lender"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="home_loan_limit_label" class="ui-input-text" id="home_loan_limit_label">Limit: $</label>
                        <input type="text" name="home_loan_limit"  id="id_home_loan_limit" placeholder="limit"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="home_loan_current_interest_rate_label" class="ui-input-text" id="home_loan_current_interest_rate_label">Current interest rate: %</label>
                        <input type="text" name="home_loan_current_interest_rate"  id="id_home_loan_current_interest_rate" placeholder="current interest rate"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="home_loan_amount_owing_label" class="ui-input-text" id="home_loan_amount_owing_label">Amount owing:</label>
                        <input type="text" name="home_loan_amount_owing"  id="id_home_loan_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="home_loan_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="home_loan_to_be_paid_out" id="id_home_loan_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>

                    </div>

                    <div data-role="fieldcontain">
                        <label for="num_other_property_loan_label" class="ui-input-text">number other property loans</label>
                        <select name="num_of_other_property_loan" id="id_num_of_other_property_loan">
                            <option value="0">0</option>
                            <option value="1">1</option>
                            <option value="2">2</option>
                            <option value="3">3</option>
                            <option value="4">4</option>
                        </select>
                    </div>

                    <div id="id_other_property_loan1_overall">
                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property1_loan_label" class="ui-input-text" id="other_property1_loan_label"><strong>Other property loan1</strong></label>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property1_loan_lender_label" class="ui-input-text" id="other_property1_loan_lender_label">Lender:</label>
                            <input type="text" name="other_property1_loan_lender"  id="id_other_property1_loan_lender" placeholder="lender"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property1_loan_limit_label" class="ui-input-text" id="other_property1_loan_limit_label">Limit: $</label>
                            <input type="text" name="other_property1_loan_limit"  id="id_other_property1_loan_limit" placeholder="limit"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property1_loan_current_interest_rate_label" class="ui-input-text" id="other_property1_loan_current_interest_rate_label">Current interest rate: %</label>
                            <input type="text" name="other_property1_loan_current_interest_rate"  id="id_other_property1_loan_current_interest_rate" placeholder="current interest rate"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property1_amount_owing_label" class="ui-input-text" id="other_property1_amount_owing_label">Amount owing:</label>
                            <input type="text" name="other_property1_amount_owing"  id="id_other_property1_amount_owing" placeholder="amount owing"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                            <div data-role="fieldcontain">
                                <label for="other_property1_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                                <select name="other_property1_to_be_paid_out" id="id_other_property1_to_be_paid_out">
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>
                            </div>
                        </div>
                    </div>

                    <div id="id_other_property_loan2_overall">
                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property2_loan_label" class="ui-input-text" id="other_property2_loan_label"><strong>Other property loan2</strong></label>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property2_loan_lender_label" class="ui-input-text" id="other_property2_loan_lender_label">Lender:</label>
                            <input type="text" name="other_property2_loan_lender"  id="id_other_property2_loan_lender" placeholder="lender"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property2_loan_limit_label" class="ui-input-text" id="other_property2_loan_limit_label">Limit: $</label>
                            <input type="text" name="other_property2_loan_limit"  id="id_other_property2_loan_limit" placeholder="limit"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property2_loan_current_interest_rate_label" class="ui-input-text" id="other_property2_loan_current_interest_rate_label">Current interest rate: %</label>
                            <input type="text" name="other_property2_loan_current_interest_rate"  id="id_other_property2_loan_current_interest_rate" placeholder="current interest rate"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property2_amount_owing_label" class="ui-input-text" id="other_property2_amount_owing_label">Amount owing:</label>
                            <input type="text" name="other_property2_amount_owing"  id="id_other_property2_amount_owing" placeholder="amount owing"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                            <div data-role="fieldcontain">
                                <label for="other_property2_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                                <select name="other_property2_to_be_paid_out" id="id_other_property2_to_be_paid_out">
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>
                            </div>
                        </div>
                    </div>

                    <div id="id_other_property_loan3_overall">
                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property3_loan_label" class="ui-input-text" id="other_property3_loan_label"><strong>Other property loan3</strong></label>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property3_loan_lender_label" class="ui-input-text" id="other_property3_loan_lender_label">Lender:</label>
                            <input type="text" name="other_property3_loan_lender"  id="id_other_property3_loan_lender" placeholder="lender"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property3_loan_limit_label" class="ui-input-text" id="other_property3_loan_limit_label">Limit: $</label>
                            <input type="text" name="other_property3_loan_limit"  id="id_other_property3_loan_limit" placeholder="limit"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property3_loan_current_interest_rate_label" class="ui-input-text" id="other_property3_loan_current_interest_rate_label">Current interest rate: %</label>
                            <input type="text" name="other_property3_loan_current_interest_rate"  id="id_other_property3_loan_current_interest_rate" placeholder="current interest rate"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property3_amount_owing_label" class="ui-input-text" id="other_property3_amount_owing_label">Amount owing:</label>
                            <input type="text" name="other_property3_amount_owing"  id="id_other_property3_amount_owing" placeholder="amount owing"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                            <div data-role="fieldcontain">
                                <label for="other_property3_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                                <select name="other_property3_to_be_paid_out" id="id_other_property3_to_be_paid_out">
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>
                            </div>
                        </div>
                    </div>

                    <div id="id_other_property_loan4_overall">
                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property4_loan_label" class="ui-input-text" id="other_property4_loan_label"><strong>Other property loan4</strong></label>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="other_property4_loan_lender_label" class="ui-input-text" id="other_property4_loan_lender_label">Lender:</label>
                            <input type="text" name="other_property4_loan_lender"  id="id_other_property4_loan_lender" placeholder="lender"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property4_loan_limit_label" class="ui-input-text" id="other_property4_loan_limit_label">Limit: $</label>
                            <input type="text" name="other_property4_loan_limit"  id="id_other_property4_loan_limit" placeholder="limit"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property4_loan_current_interest_rate_label" class="ui-input-text" id="other_property4_loan_current_interest_rate_label">Current interest rate: %</label>
                            <input type="text" name="other_property4_loan_current_interest_rate"  id="id_other_property4_loan_current_interest_rate" placeholder="current interest rate"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            <label for="other_property4_amount_owing_label" class="ui-input-text" id="other_property4_amount_owing_label">Amount owing:</label>
                            <input type="text" name="other_property4_amount_owing"  id="id_other_property4_amount_owing" placeholder="amount owing"
                            value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                            <div data-role="fieldcontain">
                                <label for="other_property4_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                                <select name="other_property4_to_be_paid_out" id="id_other_property4_to_be_paid_out">
                                    <option value="Yes">Yes</option>
                                    <option value="No">No</option>
                                </select>
                            </div>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="credit_card_label" class="ui-input-text" id="credit_card_label"><strong>Credit card(s)</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="credit_card_total_limit_label" class="ui-input-text" id="credit_card_total_limit_label">Total limits: $</label>

                        <input type="hidden" name="credit_card_title_label"  value="creditcard" id="id_credit_card_total_limit_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="credit_card_total_limit"  id="id_credit_card_total_limit" placeholder="total limits"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <label for="credit_card_amount_owing_label" class="ui-input-text" id="credit_card_amount_owing_label">Amount owing:</label>
                        <input type="text" name="credit_card_amount_owing"  id="id_credit_card_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="othcredit_card_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="credit_card_to_be_paid_out" id="id_credit_card_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="store_card_label" class="ui-input-text" id="store_card_label"><strong>Store card(s)</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="store_card_total_limit_label" class="ui-input-text" id="store_card_total_limit_label">Total limits: $</label>

                        <input type="hidden" name="store_card_title_label"  value="storecard" id="id_credit_card_total_limit_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="store_card_total_limit"  id="id_store_card_total_limit" placeholder="total limits"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <label for="store_card_amount_owing_label" class="ui-input-text" id="store_card_amount_owing_label">Amount owing:</label>
                        <input type="text" name="store_card_amount_owing"  id="id_store_card_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="store_card_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="store_card_to_be_paid_out" id="id_store_card_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="margin_loans_label" class="ui-input-text" id="margin_loans_label"><strong>Margin loan(s)</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">

                        <label for="margin_loans_amount_owing_label" class="ui-input-text" id="margin_loans_amount_owing_label">Amount owing:</label>

                        <input type="hidden" name="margin_loan_title_label"  value="marginloan" id="id_margin_loan_amount_owing_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="margin_loans_amount_owing"  id="id_margin_loans_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="margin_loans_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="margin_loans_to_be_paid_out" id="id_margin_loans_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="vehicle_finance_label" class="ui-input-text" id="vehicle_finance_label"><strong>Vehicle finance</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">

                        <label for="vehicle_finance_amount_owing_label" class="ui-input-text" id="vehicle_finance_amount_owing_label">Amount owing:</label>

                        <input type="hidden" name="vehicle_finanace_title_label"  value="vehiclefinance" id="id_margin_loan_amount_owing_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="vehicle_finance_amount_owing"  id="id_vehicle_finance_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="vehicle_finance_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="vehicle_finance_to_be_paid_out" id="id_vehicle_finance_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="contingent_liabilities_label" class="ui-input-text" id="contingent_liabilities_label"><strong>Contingent liabilities</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">

                        <label for="contingent_liabilities_amount_owing_label" class="ui-input-text" id="contingent_liabilities_amount_owing_label">Amount owing:</label>

                        <input type="hidden" name="contingent_liabilities_title_label"  value="contingentliabilities" id="id_margin_loan_amount_owing_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="contingent_liabilities_amount_owing"  id="id_contingent_liabilities_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="contingent_liabilities_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="contingent_liabilities_to_be_paid_out" id="id_contingent_liabilities_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="personal_loans_label" class="ui-input-text" id="personal_loans_label"><strong>Personal loans</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">

                        <label for="personal_loans_amount_owing_label" class="ui-input-text" id="personal_loans_amount_owing_label">Amount owing:</label>

                        <input type="hidden" name="personal_loans_label"  value="personalloans" id="id_margin_loan_amount_owing_label"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <input type="text" name="personal_loans_amount_owing"  id="id_personal_loans_amount_owing" placeholder="amount owing"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">

                        <div data-role="fieldcontain">
                            <label for="personal_loans_to_be_paid_out_label" class="ui-input-text">To be paid out:</label>
                            <select name="personal_loans_to_be_paid_out" id="id_personal_loans_to_be_paid_out">
                                <option value="Yes">Yes</option>
                                <option value="No">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="total_amount_owing" class="ui-input-text" id="total_amount_owing">Total amount owing:</label>
                        <label for="cal_total_amount_owing" class="ui-input-text" id="cal_total_amount_owing">calulated Total</label>
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#monthly_gross_income" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                    </fieldset>

                </div>
            </div>

            <div data-role="page" id="monthly_gross_income">

                <div data-role="header">
                    <h1>Monthly Gross Income</h1>
                </div>

                <div data-role="content">

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="gross_salary_label" class="ui-input-text" id="gross_salary_label"><strong>Gross salary</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="gross_salary_applicant_1_label" class="ui-input-text" id="id_gross_salary_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="gross_salary_applicant_1"  id="id_gross_salary_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="gross_salary_applicant_2_label" class="ui-input-text" id="id_gross_salary_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="gross_salary_applicant_2"  id="id_gross_salary_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="overtime_label" class="ui-input-text" id="overtime_label"><strong>Overtime</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="overtime_applicant_1_label" class="ui-input-text" id="id_overtime_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="overtime_applicant_1"  id="id_overtime_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="overtime_applicant_2_label" class="ui-input-text" id="id_overtime_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="overtime_applicant_2"  id="id_overtime_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="comission_bonus_label" class="ui-input-text" id="comission_bonus_label"><strong>Commission/Bonus</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="comission_bonus_applicant_1_label" class="ui-input-text" id="id_comission_bonus_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="comission_bonus_applicant_1"  id="id_comission_bonus_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="comission_bonus_applicant_2_label" class="ui-input-text" id="id_comission_bonus_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="comission_bonus_applicant_2"  id="id_comission_bonus_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rental_income_label" class="ui-input-text" id="rental_income_label"><strong>Rental income</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rental_income_applicant_1_label" class="ui-input-text" id="id_rental_income_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="rental_income_applicant_1"  id="id_rental_income_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rental_income_applicant_2_label" class="ui-input-text" id="id_rental_income_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="rental_income_applicant_2"  id="id_rental_income_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="dividend_interest_income_label" class="ui-input-text" id="dividend_interest_income_label"><strong>Dividen/Interest income</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="dividend_interest_income_applicant_1_label" class="ui-input-text" id="id_dividend_interest_income_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="dividend_interest_income_applicant_1"  id="dividend_interest_income_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="dividend_interest_income_applicant_2_label" class="ui-input-text" id="id_dividend_interest_income_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="dividend_interest_income_applicant_2"  id="id_dividend_interest_income_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="family_allowance_label" class="ui-input-text" id="family_allowance_income_label"><strong>Family allowance</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="family_allowance_applicant_1_label" class="ui-input-text" id="id_family_allowance_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="family_allowance_income_applicant_1"  id="family_allowance_income_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="family_allowance_applicant_2_label" class="ui-input-text" id="id_family_allowance_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="family_allowance_income_applicant_2"  id="id_family_allowance_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="motor_vehicle_allowance_label" class="ui-input-text" id="motor_vehicle_allowance_label"><strong>Motor vehicle allowance</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="motor_vehicle_allowance_applicant_1_label" class="ui-input-text" id="id_motor_vehicle_allowance_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="motor_vehicle_allowance_applicant_1"  id="motor_vehicle_allowance_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="motor_vehicle_allowance_applicant_2_label" class="ui-input-text" id="id_motor_vehicle_allowance_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="motor_vehicle_allowance_applicant_2"  id="id_motor_vehicle_allowance_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="foreign_income_label" class="ui-input-text" id="foreign_income_label"><strong>Foreign income</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="foreign_income_specify_applicant_1_label" class="ui-input-text" id="id_foreign_income_specify_applicant_1_label">Applicant 1 specify country:</label>
                        <input type="text" name="foreign_income_specify_applicant_1"  id="foreign_income_specify_applicant_1" placeholder="country"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="foreign_income_applicant_1_label" class="ui-input-text" id="id_foreign_income_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="foreign_income_applicant_1"  id="foreign_income_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="foreign_income_specify_applicant_2_label" class="ui-input-text" id="id_foreign_income_specify_applicant_2_label">Applicant 2 specify country:</label>
                        <input type="text" name="foreign_income_specify_applicant_2"  id="foreign_income_specify_applicant_2" placeholder="country"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="foreign_income_specify_applicant_2_label" class="ui-input-text" id="id_foreign_income_specify_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="foreign_income_applicant_2"  id="foreign_income_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_income_label" class="ui-input-text" id="other_income_label"><strong>Other income</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_income_applicant_1_label" class="ui-input-text" id="id_other_income_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="other_income_applicant_1"  id="other_income_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_income_applicant_2_label" class="ui-input-text" id="id_other_income_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="other_income_applicant_2"  id="id_other_income_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#monthly_expenses" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                         
                    </fieldset>
                </div>
            </div>

            <div data-role="page" id="monthly_expenses">

                <div data-role="header">
                    <h1>Monthly Expenses</h1>
                </div>

                <div data-role="content">

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="living_expense_label" class="ui-input-text" id="living_expense_label"><strong>Living expenses</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="living_expense_applicant_1_label" class="ui-input-text" id="id_living_expense_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="living_expense_applicant_1"  id="id_living_expense_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="living_expense_applicant_2_label" class="ui-input-text" id="id_living_expense_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="living_expense_applicant_2"  id="id_living_expense_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="home_loan_payment_label" class="ui-input-text" id="home_loan_payment_label"><strong>Home loan payment</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="home_loan_payment_applicant_1_label" class="ui-input-text" id="id_home_loan_payment_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="home_loan_payment_applicant_1"  id="id_home_loan_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="home_loan_payment_applicant_2_label" class="ui-input-text" id="id_home_loan_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="home_loan_payment_applicant_2"  id="id_home_loan_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_loan_payment_label" class="ui-input-text" id="other_loan_payment_label"><strong>Other loan payments</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_loan_payment_applicant_1_label" class="ui-input-text" id="id_other_loan_payments_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="other_loan_payment_applicant_1"  id="id_other_loan_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_loan_payment_applicant_2_label" class="ui-input-text" id="id_other_loan_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="other_loan_payment_applicant_2"  id="id_other_loan_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="credit_card_payment_label" class="ui-input-text" id="credit_card_payment_label"><strong>Credit card payments</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="credit_card_payment_applicant_1_label" class="ui-input-text" id="id_credit_card_payment_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="credit_card_payment_applicant_1"  id="id_credit_card_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="credit_card_payment_applicant_2_label" class="ui-input-text" id="id_credit_card_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="credit_card_payment_applicant_2"  id="id_credit_card_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="store_card_payment_label" class="ui-input-text" id="store_card_payment_label"><strong>Store card payments</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="store_card_payment_applicant_1_label" class="ui-input-text" id="id_store_card_payment_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="store_card_payment_applicant_1"  id="store_card_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="store_card_payment_applicant_2_label" class="ui-input-text" id="id_store_card_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="store_card_payment_applicant_2"  id="id_store_card_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="vehicle_finance_payment_label" class="ui-input-text" id="fvehicle_finance_payment_label"><strong>Vehicle finance payments</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="vehicle_finance_payment_applicant_1_label" class="ui-input-text" id="id_vehicle_finance_payment_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="vehicle_finance_payment_applicant_1"  id="vehicle_finance_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="vehicle_finance_payment_applicant_2_label" class="ui-input-text" id="id_vehicle_finance_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="vehicle_finance_payment_applicant_2"  id="id_vehicle_finance_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="personal_loan_payment_label" class="ui-input-text" id="personal_loan_payment_label"><strong>Personal loan payments</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="personal_loan_payment_applicant_1_label" class="ui-input-text" id="id_personal_loan_payment_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="personal_loan_payment_applicant_1"  id="personal_loan_payment_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="personal_loan_payment_applicant_2_label" class="ui-input-text" id="id_personal_loan_payment_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="personal_loan_payment_applicant_2"  id="id_personal_loan_payment_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rent_board_label" class="ui-input-text" id="foreign_income_label"><strong>Foreign income</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rent_board_label" class="ui-input-text" id="rent_board_label"><strong>Rent/Board</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rent_board_applicant_1_label" class="ui-input-text" id="id_rent_board_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="rent_board_applicant_1"  id="rent_board_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="rent_board_applicant_2_label" class="ui-input-text" id="id_rent_board_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="rent_board_applicant_2"  id="id_rent_board_applicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_label" class="ui-input-text" id="other_label"><strong>other (e.g. maintenance)</strong></label>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_specify_applicant_1_label" class="ui-input-text" id="id_other_specify_applicant_1_label">Applicant 1 specify:</label>
                        <input type="text" name="other_specify_applicant_1"  id="fother_applicant_1" placeholder="other"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="other_applicant_1_label" class="ui-input-text" id="id_other_applicant_1_label">Applicant 1:</label>
                        <input type="text" name="other_applicant_1"  id="other_applicant_1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="other_specify_applicant_2_label" class="ui-input-text" id="id_other_specify_applicant_2_label">Applicant 2 specify:</label>
                        <input type="text" name="other_specify_applicant_2"  id="other_specify_applicant_2" placeholder="country"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <label for="other_applicant_2_label" class="ui-input-text" id="id_other_applicant_2_label">Applicant 2:</label>
                        <input type="text" name="other_applicant_2"  id="other_pplicant_2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#securityproperty" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                        <div class="ui-block-b">
                            <a href="#insurance_personal_details" data-role="button" data-theme="b" data-transition="fade" id="personal_details_next_btn">insurance personal</a>
                        </div>
                    </fieldset>
                </div>

            </div>

            <div data-role="page" id="securityproperty">

                <div data-role="header">
                    <h1>Security Property</h1>
                </div>

                <div id="section_8_important_notes">
                    <p>
                        - Please photocopy this page if there are more than two security properties
                    </p>
                    <p>
                        - For properties being purchased, the applicant's name must be identical to that listed on the Contract for Sale, Certificate of Title and Mortgage documents.
                    </p>

                </div>

                <div id="security_property1">
                    <h3>Security Property 1</h3>

                    <div data-role="fieldcontain">
                        <label for="type_of_property1_label" class="ui-input-text">Type of Property</label>
                        <select name="type_of_property1" id="id_type_of_property1">
                            <option value="house">House</option>
                            <option value="flatunit">Flat/Unit</option>
                            <option value="companytitleflat/unit">Company title flat/unit</option>
                            <option value="land">Land</option>
                            <option value="duplex">Duplex</option>
                            <option value="studio">Studio</option>
                            <option value="townhouse/Villa">Townhouse/Villa</option>
                        </select>
                    </div>

                    <div id="id_div_if_flat1">
                        <div data-role="fieldcontain" >
                            <label for="if_flat_unit1_label" id="id_if_flat_unit1_label"class="ui-input-text">If a flat/unit, is it in a complex of more tan 30 flats/units?</label>
                            <select name="if_flat_unit1" id="id_if_flat_unit1">
                                <option value="yes">Yes</option>
                                <option value="no">No</option>
                            </select>
                        </div>
                    </div>

                    <div id="id_div_if_studio1">
                        <div data-role="fieldcontain" >
                            <label for="if_studio1_label" id="id_if_studio1_label"class="ui-input-text">If a studio, is the size of the property less than 45m?</label>
                            <select name="if_studio1" id="id_if_studio1">
                                <option value="yes">Yes</option>
                                <option value="no">No</option>
                            </select>
                        </div>
                    </div>
                    <div data-role="fieldcontain">
                        <label for="property_status_label" class="ui-input-text">Status</label>
                        <select name="property_status1" id="id_property_status1">
                            <option value="already_owned">Already owned</option>
                            <option value="to_be_purchased">To be purchased</option>
                            <option value="mortaged">Mortaged</option>
                            <option value="to_be_refinanced">To be refinanced</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="property_use_label" class="ui-input-text">property use</label>
                        <select name="property_use1" id="id_property_use1">
                            <option value="live_in">Live in</option>
                            <option value="investment">Investment</option>
                        </select>

                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="purchased_price_estimated_value1_label" class="ui-input-text" id="id_purchased_price_estimated_value1_label">Purchase price/estimated value: $</label>
                        <input type="text" name="purchased_price_estimated_value1"  id="id_purchased_price_estimated_value1" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="settlement_date1" class="ui-input-text" id="id_settlement_date1_label">Settlement date: </label>
                        <input id="id_settlement_date1" type="date" name="settlement_date1">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="title_particulars1_label" class="ui-input-text" id="id_title_particulars1_label">Title particulars: </label>
                        <input type="text" name="title_particulars1"  id="id_title_particulars1" placeholder="title particulars"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="title_name1_label" class="ui-input-text" id="id_title_name1_label">Name or proposed name to be on title for this security property: </label>
                        <input type="text" name="title_name1"  id="id_title_name1" placeholder="title name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="address_security_property1_label" class="ui-input-text" id="id_address_security_property1_label">Address of security property: </label>
                        <input type="text" name="address_security_property1"  id="id_address_security_property1" placeholder="address"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <input type="text" name="address_postalcode_security_property1"  id="id_address_postalcode_security_property1" placeholder="postalcode"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:35%">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="contact_person_valuation1_label" class="ui-input-text">Contact person for valuation</label>
                        <select name="contact_person_valuation1" id="id_contact_person_valuation1">
                            <option value="tenant">Tenant</option>
                            <option value="owner">Owner</option>
                            <option value="agent">Agent</option>
                        </select>

                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="name_contact_person_valuation1_label" class="ui-input-text" id="id_name_contact_person_valuation1_label">Name of contact person for valuation: </label>
                        <input type="text" name="name_contact_person_valuation1"  id="id_name_contact_person_valuation1" placeholder="valuation contact name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div>
                        <label for="contact_person_phone_number1" class="ui-input-text">Phone Number:</label>
                        <div class="ui-grid-a">
                            <div class="ui-block-a" style="width:20%">
                                <input type="text" name="contact_person_phone_number1_ext" id="id_contact_person_phone_number1_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                            </div>
                            <div class="ui-block-b" style="width:80%">
                                <input type="text" name="contact_person_phone_number1" id="contact_person_phone_number1" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="phone number">
                            </div>
                        </div>
                    </div>

                    <div>
                        <label for="contact_person_fax_number1" class="ui-input-text">Fax Number:</label>
                        <div class="ui-grid-a">
                            <div class="ui-block-a" style="width:20%">
                                <input type="text" name="contact_person_fax_number1_ext" id="id_contact_person_fax_number1_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                            </div>
                            <div class="ui-block-b" style="width:80%">
                                <input type="text" name="contact_person_fax_number1" id="contact_person_fax_number1" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="fax number">
                            </div>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="contact_person_mobile_number1_label" class="ui-input-text" id="id_contact_person_mobile_number1_label">Mobile phone number: </label>
                        <input type="text" name="contact_person_mobile_number1"  id="id_contact_person_mobile_number1" placeholder="valuation contact name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>
                </div>

                <div id="security_property2">
                    <h3>Security Property 2</h3>

                    <div data-role="fieldcontain">
                        <label for="type_of_property2_label" class="ui-input-text">Type of Property</label>
                        <select name="type_of_property2" id="id_type_of_property2">
                            <option value="house">House</option>
                            <option value="flatunit">Flat/Unit</option>
                            <option value="companytitleflat/unit">Company title flat/unit</option>
                            <option value="land">Land</option>
                            <option value="duplex">Duplex</option>
                            <option value="studio">Studio</option>
                            <option value="townhouse/Villa">Townhouse/Villa</option>
                        </select>
                    </div>

                    <div id="id_div_if_flat2">
                        <div data-role="fieldcontain">
                            <label for="if_flat_unit2_label" id="id_if_flat_unit2_label" class="ui-input-text">If a flat/unit, is it in a complex of more tan 30 flats/units?</label>
                            <select name="if_flat_unit2" id="id_if_flat_unit2">
                                <option value="yes">Yes</option>
                                <option value="no">No</option>
                            </select>
                        </div>
                    </div>

                    <div id="id_div_if_studio2">
                        <div data-role="fieldcontain">
                            <label for="if_studio2_label" id="id_if_studio2_label"class="ui-input-text">If a studio, is the size of the property less than 45m?</label>
                            <select name="if_studio2" id="id_if_studio2">
                                <option value="yes">Yes</option>
                                <option value="no">No</option>
                            </select>
                        </div>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="property_status_label" class="ui-input-text">Status</label>
                        <select name="property_status2" id="id_property_status1">
                            <option value="already_owned">Already owned</option>
                            <option value="to_be_purchased">To be purchased</option>
                            <option value="mortaged">Mortaged</option>
                            <option value="to_be_refinanced">To be refinanced</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain">
                        <label for="property_use_label" class="ui-input-text">Status</label>
                        <select name="property_use2" id="id_property_use2">
                            <option value="live_in">Live in</option>
                            <option value="investment">Investment</option>
                        </select>

                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="purchased_price_estimated_value2_label" class="ui-input-text" id="id_purchased_price_estimated_value1_labe2">Purchase price/estimated value: $</label>
                        <input type="text" name="purchased_price_estimated_value2"  id="id_purchased_price_estimated_value2" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="settlement_date2" class="ui-input-text" id="id_settlement_date2_label">Settlement date: </label>
                        <input id="id_settlement_date2" type="date" name="settlement_date2">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="title_particulars2_label" class="ui-input-text" id="id_title_particulars2_label">Title particulars: </label>
                        <input type="text" name="title_particulars2"  id="id_title_particulars2" placeholder="title particulars"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="title_name2_label" class="ui-input-text" id="id_title_name2_label">Name or proposed name to be on title for this security property: </label>
                        <input type="text" name="title_name2"  id="id_title_name2" placeholder="title name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="address_security_property2_label" class="ui-input-text" id="id_address_security_property2_label">Address of security property: </label>
                        <input type="text" name="address_security_property2"  id="id_address_security_property2" placeholder="address"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        <input type="text" name="address_postalcode_security_property2"  id="id_address_postalcode_security_property2" placeholder="postalcode"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:35%">
                    </div>

                    <div data-role="fieldcontain">
                        <label for="contact_person_valuation2_label" class="ui-input-text">Status</label>
                        <select name="contact_person_valuation2" id="id_contact_person_valuation2">
                            <option value="tenant">Tenant</option>
                            <option value="owner">Owner</option>
                            <option value="agent">Agent</option>
                        </select>

                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="name_contact_person_valuation2_label" class="ui-input-text" id="id_name_contact_person_valuation2_label">Name of contact person for valuation: </label>
                        <input type="text" name="name_contact_person_valuation2"  id="id_name_contact_person_valuation2" placeholder="valuation contact name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                    <div>
                        <label for="contact_person_phone_number2" class="ui-input-text">Phone Number:</label>
                        <div class="ui-grid-a">
                            <div class="ui-block-a" style="width:20%">
                                <input type="text" name="contact_person_phone_number2_ext" id="id_contact_person_phone_number2_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                            </div>
                            <div class="ui-block-b" style="width:80%">
                                <input type="text" name="contact_person_phone_number2" id="contact_person_phone_number2" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="phone number">
                            </div>
                        </div>
                    </div>

                    <div>
                        <label for="contact_person_fax_number2" class="ui-input-text">Fax Number:</label>
                        <div class="ui-grid-a">
                            <div class="ui-block-a" style="width:20%">
                                <input type="text" name="contact_person_fax_number2_ext" id="id_contact_person_fax_number2_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                            </div>
                            <div class="ui-block-b" style="width:80%">
                                <input type="text" name="contact_person_fax_number2" id="contact_person_fax_number2" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="fax number">
                            </div>
                        </div>
                    </div>

                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="contact_person_mobile_number2_label" class="ui-input-text" id="id_contact_person_mobile_number2_label">Mobile phone number: </label>
                        <input type="text" name="contact_person_mobile_number2"  id="id_contact_person_mobile_number2" placeholder="valuation contact name"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>
                </div>

                <div id="deposit_under_lien">
                    <h3>Deposit Under Lien</h3>
                </div>

                <div data-role="fieldcontain">
                    <label for="deposit_under_lien_label" class="ui-input-text">Is a deposit under lien to be taken? Note: The deposit uner lien MUST be a team deposit held with HSBC in the same name as the borrowers and be in Australian Dollars. It CANNOT be part of the loan proceeds.</label>
                    <select name="deposit_under_lien" id="id_deposit_under_lien">
                        <option value="no">No</option>
                        <option value="yes">Yes</option>
                    </select>
                </div>

                <div id="id_div_deposit_under_lien">
                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="deposit_under_lien_amount_label" class="ui-input-text" id="id_deposit_under_lien_amount_label">Specify amount :$ </label>
                        <input type="text" name="deposit_under_lien_amount"  id="id_deposit_under_lien_amount" placeholder="amount"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>
                    <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                        <label for="deposit_under_lien_acc_label" class="ui-input-text" id="id_deposit_under_lien_acc_label">Account number: </label>
                        <input type="text" name="deposit_under_lien_acc"  id="id_deposit_under_lien_acc" placeholder="Account number"
                        value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    </div>

                </div>

                <fieldset class="ui-grid-a">
                    <div class="ui-block-a">
                        <button type="reset" data-theme="c">
                            Reset
                        </button>
                    </div>
                    <div class="ui-block-b">
                        <a href="#solicitor_conveyancer_details" data-role="button" data-theme="b" data-transition="fade">Next</a>
                    </div>
                </fieldset>

            </div>

            <div data-role="page" id="solicitor_conveyancer_details">

                <div data-role="header">
                    <h1>Solicitor/Conveyancer details</h1>
                </div>

                <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                    <label for="name_of_firm_label" class="ui-input-text" id="id_name_of_firm_label">Name of firm: </label>
                    <input type="text" name="name_of_firm"  id="id_name_of_firm" placeholder="name of firm"
                    value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                </div>

                <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                    <label for="name_of_contact_person_at_firm_label" class="ui-input-text" id="id_name_of_contact_person_at_firm_label">Name of contact person: </label>
                    <input type="text" name="name_of_contact_person_at_firm"  id="id_name_of_contact_person_at_firm" placeholder="name of contact person at firm"
                    value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                </div>

                <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                    <label for="address_solicitor_conveyancer_label" class="ui-input-text" id="id_address_solicitor_conveyancer_label">Address: </label>
                    <input type="text" name="address_solicitor_conveyancer"  id="id_address_solicitor_conveyancer" placeholder="address"
                    value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                    <input type="text" name="address_postalcode_solicitor_conveyancer"  id="id_address_postalcode_solicitor_conveyancer" placeholder="postalcode"
                    value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" style="width:35%">
                </div>

                <div>
                    <label for="solicitor_conveyancer_phone_number" class="ui-input-text">Phone Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="solicitor_conveyancer_phone_number_ext" id="id_solicitor_conveyancer_phone_number_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="solicitor_conveyancer_phone_number" id="solicitor_conveyancer_phone_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="phone number">
                        </div>
                    </div>
                </div>

                <div>
                    <label for="solicitor_conveyancer_fax_number" class="ui-input-text">Fax Number:</label>
                    <div class="ui-grid-a">
                        <div class="ui-block-a" style="width:20%">
                            <input type="text" name="solicitor_conveyancer_fax_number_ext" id="id_solicitor_conveyancer_fax_number_ext" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="idd">
                        </div>
                        <div class="ui-block-b" style="width:80%">
                            <input type="text" name="solicitor_conveyancer_fax_number" id="solicitor_conveyancer_fax_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset" placeholder="fax number">
                        </div>
                    </div>
                </div>

                <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                    <label for="solicitor_conveyancer_email_label" class="ui-input-text" id="id_solicitor_conveyancer_email_label">Email address: </label>
                    <input type="text" name="solicitor_conveyancer_email"  id="id_solicitor_conveyancer_email" placeholder="email"
                    value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                </div>

                <div data-role="fieldcontain">
                    <label for="solicitor_conveyancer_document_sent_label" class="ui-input-text">Where would like all loan and associated documents sent?</label>
                    <select name="solicitor_conveyancer_document_sent" id="id_solicitor_conveyancer_document_sent">
                        <option value="direct_to_solicitor_conveyancer">Direct to your solictor/conveyancer</option>
                        <option value="directly_to_you">Directly to you</option>
                    </select>

                </div>

                <fieldset class="ui-grid-a">
                    <div class="ui-block-a">
                        <button type="reset" data-theme="c">
                            Reset
                        </button>
                    </div>
                    <div class="ui-block-b">
                        <a href="#id_loan_fee_details" data-role="button" data-theme="b" data-transition="fade">Next</a>
                    </div>
                </fieldset>

            </div>

            <div data-role="page" id="id_loan_fee_details">

                <div data-role="header">
                    <h1>Loan Fee Details</h1>
                </div>

                <div data-role="content" >
                    <p>
                        Note: Establishment fees will be collected out of loan proceeds at settlement as per your Letter of Offer.
                    </p>

                    <div id="loan_fee_details" data-role="content">

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="no_of_properties_to_be_value_label" class="ui-input-text">Number of properties to be valued:</label>
                            <input type="text" name="no_of_properties_to_be_value" id="id_no_of_properties_to_be_value" value clas"ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="establishment_fee_label" class="ui-input-text">Establishment fee (payable at settlement):</label>
                            <input type="text" name="establishment_fee" id="id_establishment_fee" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="fixed_rate_lock_fee_label" class="ui-input-text">Fixed Rate Lock fee (payable upfront at application & non-refundable):</label>
                            <input type="text" name="fixed_rate_lock_fee" id="id_fixed_Rate_lock_fee" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="valuation_fee" class="ui-input-text">Valuation fee(payable upfront at application & non-refundable):</label>
                            <input type="text" name="valuation_fee" id="id_valuation_Fee" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                        <br />

                        <div data-role="fieldcontain">
                            <label for="payment_type" class="ui-input-text"><strong>How would you like to pay your upfront fees?</strong></label>
                            <select name="fee_payment_type" id="id_payment_type">
                                <option value="debit_my_HSBC">Debit my HSBC</option>
                                <option value="cheque">Cheque</option>

                            </select>
                        </div>

                        <div id="id_HSBC_bank_acc">
                            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br" >
                                <label for="HSBC_account" class="ui-input-text">HSBC a/c</label>
                                <input type="text" name="HSBC_account" id="id_HSBC_account_num" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            </div>
                        </div>

                        <fieldset class="ui-grid-a">
                            <div class="ui-block-a">
                                <button type="reset" data-theme="c">
                                    Reset
                                </button>
                            </div>
                            <div class="ui-block-b">
                                <a href="#id_building_contents_insurance" data-role="button" data-theme="b" data-transition="fade">Next</a>
                            </div>
                        </fieldset>
                    </div>
                </div>
            </div>
            <div data-role="page" id="id_building_contents_insurance">

                <div data-role="header">
                    <h1>Building And Contents Insurance</h1>
                </div>
                <div data-role="content" data-theme="c">

                    <p>
                        It is a <b>compulsory condition </b>of your loan to have building insurance (strata         titled properties are exempt) in place at the time of loan settlement. The choice of insurer is yours, however, the bank is able to arrange your insurance withe Vero Insurance Ltd.
                    </p>

                    <div data-role="fieldcontain">
                        <label for="insurance_quotation_label" class="ui-input-text">Would you like us to provide you with an insurance quotation?</label>
                        <select name="insurance_quotation" id="id_insurance_quotation">
                            <option value="yes">Yes</option>
                            <option value="no">No - I/We wish to make alternative arrangements for our insurance. <b>Note:</b> Confirmaiton of building insrance will be required before settlement.</option>
                        </select>
                    </div>

                    <div data-role="fieldcontain" id="id_quotation_yes">
                        <select name="insurance_quotation_yes" id="id_insurance_quotation">
                            <option value="contents">Contents</option>
                            <option value="building">Building</option>
                            <option value="combine_building_contents">Combined building and contents</option>
                        </select>
                    </div>

                    <div id="id_existing_insurance">
                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br" >
                            <label for="existing_insurance_label" class="ui-input-text">If you have existing insurance please provide
                                the name of your provider (insurance provider must be acceptable to HSBC</label>
                            <input type="text" name="existing_insurance" id="id_existing_insurance" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>
                    </div>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Reset
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#id_life_insurance_mortgage_protection" data-role="button" data-theme="b" data-transition="fade">Next</a>
                        </div>
                    </fieldset>

                </div>
            </div>

            <div data-role="page" id="id_life_insurance_mortgage_protection">

                <div data-role="header">
                    <h1>Life insurance Mortgage Protection</h1>
                </div>
                <div data-role="content" data-theme="c">
                    <p>
                        It is not a pleasant thought, but have you considered how your family would cope with mortgage repayments if something were to happen to you or your partner? HSBC can arrange both life and mortgage protection insurances to ensure that your most valuable assests are securly portected.
                    </p>
                    <br />

                    <label for="form3_qus_label" class="ui-input-text">Can we assist you with life or mortgage protection insurance?</label>

                    <select name="assist_life_mortgage_insurance" id="id_assist_life_mortage_insurance">
                        <option value="yes">YES (I/we would like to be provided with the following):</option>
                        <option value="no">NO(I/We wish to make alternative arragements)</option>
                    </select>

                    <div id="id_assist_life_mortage_insurance_type_layout">
                         <select name="assist_life_mortage_insurance_type" id="id_assist_life_mortage_insurance_Type">
                        <option value="review_life_insurance">Review my life insurance needs</option>
                        <option value="quote_mortage_protection">Quote for mortgage protection</option>
                    </select>
                        
                    </div>
                    
                    <p>
                    Review of my Life insurance needs  </p>
                    <p> Quote for Mortgage Protection</p>

                    <br />

                    <p>
                    # Building, Contents, Life and Mortgage Protection Insurances are not deposit products or other liabilities of HSBC Bank Australia Limited ("HSBC"). HSBC does not guarantee the performance of, or in any wat stand behind, the issuers or their may receive commissions for their sale. You should consider the relevant Product Discloser Statement in deiding whether to acquire any of these products.
                    <br /> </p>
                    <br />

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a"><button type="reset" data-theme="c">Reset</button></div>
                        <div class="ui-block-b"><button type="submit" id="loan_application_submit" data-theme="b">Submit</button></div>
                        <div class="ui-block-c"><a href="#insurance_personal_details" data-role="button" data-theme="b" data-transition="fade">Next</a></div>
                        	
                    </fieldset>

                    </div>
                  	<!--</form>-->

				</div>
				
				  <div data-role="page" id="insurance_personal_details">
			
                    <div data-role="header">
                    <h1>Insurance Personal Details</h1>
                    </div>
                    
                   <div data-role="content" data-theme="c">
                   	
                   	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="agency_num" class="ui-input-text">Agency number:</label>
						<input type="text" name="agency_num" id="id_agency_number" placeholder="Agency number" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="office" class="ui-input-text">Office:</label>
						<input type="text" name="office" id="id_agency_number" placeholder="Office" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="receive_date" class="ui-input-text">Receive Date:</label>
						<input type="text" name="receive_date" id="id_receive_date" placeholder="Receive date" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
                   	
                   	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="proposal_number" class="ui-input-text">Proposal Number:</label>
						<input type="text" name="proposal_number" id="id_proposal_number" placeholder="Proposal number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
                   	
                   	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="mfi_account_num" class="ui-input-text">MFI Account Number:</label>
						<input type="text" name="proposal_number" id="id_proposal_number" placeholder="Proposal number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="life_assurance_proposal" class="ui-input-text">Proposal for Life Assurance:</label>
						<input type="text" name="life_assurance_proposal" id="id_life_assurance_proposal" placeholder="Proposal for Life Assurance" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					
                   	
                  	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="title" class="ui-input-text">Title:</label>
						<input type="text" name="title" id="id_insurance_title" placeholder="Title" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="surname" class="ui-input-text">Surname:</label>
						<input type="text" name="surname" id="id_insurance_surname" placeholder="Surname" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>

					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="givenname" class="ui-input-text">Given Name(s):</label>
						<input type="text" name="givenname" id="id_insurance_givenname" placeholder="Given Name" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					<div data-role="fieldcontain">
						<label for="gender" class="ui-input-text">Gender:</label>
						<select name="gender" id="id_insurance_gender">
							<option value="Male">Male</option>
							<option value="Female">Female</option>
						</select>
					</div>
					
					<div data-role="fieldcontain">
						
						<label for="DOB" class="ui-input-text">Date of Birth:</label>
						 <input id="id_insurance_dob" type="date" name="dob">
						
					</div>	
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="No_children" class="ui-input-text">Number of Children:</label>
						<input type="text" name="No_children" id="id_No_Children" placeholder="Number of Children" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
						
					</div>
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="No_dependants" class="ui-input-text">Number of other Dependants :</label>
						<input type="text" name="No_dependants" id="id_No_dependants" placeholder="Number of Other Dependants" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					
					<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
				
					 <label for="nationality" class="ui-input-text">Nationality:</label>
						<select name="nationality" id="id_insurance_nationality">
						    <option value="Singapore Citizen">Singapore Citizen</option>
						    <option value="Singapore Permanent Resident">Singapore Permanent Resident/Employment Pass/Work Permit</option>
						    <option value="others">Others (eg. Dependant Pass/Long Term Visit Pass/Student Pass/Social Visit Pass, etc.)</option>
	                    </select>
					</div>
					
				<div id ="id_citizen" >
				    	<div data-role="fieldcontain">                  

				    <label for="PR_qus" class="ui-input-text">Have you resided outside Singapore continuously for 5 years or more preceding 
						the date of proposal?</label>
				    <select name="citizen_qus" id="id_citizen_qus">
				    	<option value="yes">Yes</option>
				    	<option value="no">No</option>
			      	</select>
			      
			     	</div>
			     </div>
			     
			      <div id ="id_PR" >
				    <div data-role="fieldcontain">                  

				    <label for="PR_qus" class="ui-input-text">Have you resided in Singapore for less than 183 days in the 12 months preceding 
						the date of proposal?</label>
				    <select name="PR_qus" id="id_PR_qus">
					    <option value="yes">Yes</option>
					    <option value="no">No</option>
			      	</select>
			      	
			      </div>
			     </div>
			     
			     <div id ="id_others" >
				     <div data-role="fieldcontain">
					 	<label for="others_qus" class="ui-input-text">Have you resided in Singapore for any periods of time, of which each period was 
					    	less than 90 days in the 12 months preceding the date of proposal? </label>
					  	<select name="others_qus" id="id_others_qus">
						    <option value="yes">Yes</option>
						    <option value="no">No</option>
				      	</select>
	                </div>
               	</div>
               	
               	<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="NRIC" class="ui-input-text">NRIC/Passport/BC No:</label>
					<input type="text" name="NRIC" id="id_NRIC" placeholder="NRIC/Passport/ BC No" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
				
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="POB" class="ui-input-text">Place of Birth:</label>
					<input type="text" name="POB" id="id_POB" placeholder="Place of Birth" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
				
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Relationship" class="ui-input-text">Relationship to Life Assured:</label>
					<input type="text" name="Relationship" id="id_Relationship" placeholder="Rekationship to Life Assured" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
				
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Occupation" class="ui-input-text">Occupation:</label>
					<input type="text" name="Occupation" id="id_insurance_occupation" placeholder="Occupation" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>     
	       
	       
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Annual_Income" class="ui-input-text">Annual Income:</label>
					<input type="text" name="Annual_Income" id="id_Annual_Income" placeholder="Annual Income" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>    
				
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Height" class="ui-input-text">Height (m):</label>
					<input type="text" name="Height" id="id_Height" placeholder="Height" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>        
	           
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Weight" class="ui-input-text">Weight (kg):</label>
					<input type="text" name="Weight" id="id_Weight" placeholder="Weight" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
				
				
				
				
				 <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="smoke_qus" class="ui-input-text">Have you smoked any cigarettes in the past 12 months?</label>
						<select name="smoke_qus" id="id_smoke_qus">
							<option value="yes">Yes</option>
							<option value="no">No</option>
  						</select>
  				</div>	
  				
  				<div id="id_smoking_content">
    				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="Smoked_years" class="ui-input-text">Number of years smoked years:</label>
						<input type="text" name="Smoked_years" id="id_Smoked_years" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
            
    			<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="Smoked_sticks" class="ui-input-text">Number of sticks consumed daily sticks:</label>
						<input type="text" name="Smoked_sticks" id="id_Smoked_sticks" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
  				</div>
  				
  				
                <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Precise_Occupation" class="ui-input-text">Precise Occupation:</label>
					<input type="text" name="Precise_Occupation" id="id_Precise_Occupation" placeholder="Precise Occupation" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>   
				
				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Name_of_employer" class="ui-input-text">Name Of Employer:</label>
					<input type="text" name="Name_of_employer" id="id_Name_of_employer" placeholder="Name of Employer" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>   
            	
  				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Detail_of_job_duties" class="ui-input-text">Details of Job Duties:</label>
					<input type="text" name="Detail_of_job_duties" id="id_Detail_of_job_duties" placeholder="Details of Job Duties" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>   
            
            
  				<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="Nature_of_business/industry" class="ui-input-text">Nature of business/industry:</label>
					<input type="text" name="Nature_of_business/industry" id="id_Nature_of_business/industry" placeholder="Nature of bussines/industry" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>  
  				
               
                   <fieldset class="ui-grid-a">
                        <div class="ui-block-a"><button type="reset" data-theme="c">Reset</button></div>
                        <div class="ui-block-c"><a href="#insurance_page_2" data-role="button" data-theme="b" data-transition="fade">Next</a></div>
                  	</fieldset>
                  	
  				</div>
  					
             </div>  
            
            
             <div data-role="page" id="insurance_page_2">

                    <div data-role="header">
                    	<h1>Life Insurance Page2</h1>
                    </div>
                    
                    <div data-role="content" >  
						<p> <strong>1) Details of Life to be Assured </strong></p>
						<p><strong>Please complete in capital letters and tick boxes( ) as appropriate.</strong></p></br>
        				<p><strong>2)Details of Proposer (if different from Life to be Assured) - Please complete in capital letters</strong></p>
        				<p><strong>Please complete in capital letters and tick boxes( ) as appropriate.</strong></p></br>
        			
        			<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="Annual_Income2" class="ui-input-text">Annual Income:</label>
						<input type="text" name="Annual_Income2" id="id_Annual_Income2" placeholder="annual income" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
		        	</div>
		        	
		        	 <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
						<label for="address_proposer" class="ui-input-text">Address of Proposer:</label>
						<input type="text" name="address_proposer" id="id_address_proposer" placeholder="Address of Propser" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
					</div>
					<label for="if_condition" class="ui-input-text"><strong> If the lives are not husband and wife, a letter signed by both lives giving full details of the insurable interest must be attached.</strong></label></br>

            
            	 <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="address_Residential" class="ui-input-text">Residential Address in full :</label>
					<input type="text" name="address_Residential" id="id_insurance_address_residential" placeholder="Residential Address in full" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
            
            
            
	             <label for="address_note" class="ui-input-text"><strong>The address stated here will be used on this application and updated on all your existing policy(ies). All correspondence will be sent to this 
					residential address unless you specify a mailing address. </strong></label>
				
          
             	<label for="Note" class="ui-input-text"><strong>Note: A copy of NRIC of the Proposer must be submitted. Address on NRIC submitted must tally with the address of either the residential or the mailing address stated above. Otherwise, please provide documentary proof (eg. state issued document or bank statement) of the address 
					stated in this proposal.</strong></label>
		      
		      <p><strong>
            	The mailing address will apply to this application only. If you wish to change your mailing address for your existing policy(ies), please submit 
				a separate written request.  
            </strong></p>
            
		        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
					<label for="mailing_address" class="ui-input-text">Mailing Address in full (if different from residential address):</label>
					<input type="text" name="mailing_address" id="id_insurance_mailing_address" placeholder="Mailing Address in full" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
				</div>
     
            
             <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
				<label for="email" class="ui-input-text">Home Office E-mail:</label>
				<input type="text" name="email" id="id_insurance_email" placeholder="Home Office E-Mail" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
			</div>
            
            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
				<label for="mobile_phone" class="ui-input-text">Mobile Phone:</label>
				<input type="text" name="mobile_phone" id="id_mobile_phone" placeholder="Mobile Phone" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
			</div>
            
                     
            
            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
				<label for="country_code_mobile_No" class="ui-input-text">Applicable to Oversea Country Code Mobile Number:</label>
				<input type="text" name="country_code_mobile_No" id="id_country_code_mobile_num_oversea" placeholder="County Code Mobile Number" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
			</div>
            
              <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
				<label for="mobile_oversea" class="ui-input-text">Applicable to Overseas Mobile Number:</label>
				<input type="text" name="mobile_oversea" id="id_mobile_oversea" placeholder="Oversea Mobile Number" class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
			</div>
			
			 <div data-role="fieldcontain">
				<label for="details_life_assurance" class="ui-input-text">Type of Life Assurance Proposed:</label>
				<select name="details_life_assurance" id="id_details_life_assurance">
					<option value="Basic Assurance">Basic Assurance</option>
					<option value="Supplementary Benefit">Supplementary Benefit</option>
					<option value="Disability Benefit">Disability Benefit</option>
                    <option value="Crisis Waiver">Crisis Waiver</option>
                    <option value="Early Stage Crisis Waiver">Early Stage Crisis Waiver</option>
                                   
				</select>
			</div>
            
            <div data-role="fieldcontain">
				<label for="Sum_Assured " class="ui-input-text">Sum Assured:</label>
				<select name="Sum_Assured" id="id_Sum_Assured">
					<option value="Term">Term</option>
					<option value="Premium">Premium</option>
			</select>
			</div>
            
            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                <label for="total_permium" class="ui-input-text" id="id_total_permium" >Total Premium:</label>
                <input type="text" name="total_permium"  id="id_other_real_estate_add4" placeholder="$" 
                value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
            </div>

            <div data-role="fieldcontain">
				<label for="payment_mode" class="ui-input-text">Payment Mode:</label>
				<select name="payment_mode" id="id_payment_mode">
					<option value="Monthly">Monthly</option>
					<option value="Quarterly ">Quarterly </option>
                    <option value="Half-yearly">Half-yearly</option>
					<option value="Yearly ">Yearly</option>
			</select>
			</div>
            
            
             <div data-role="fieldcontain">
				<label for="payment_method" class="ui-input-text">Payment Method:</label>
				<select name="payment_method" id="id_payment_method">
					<option value="Interbank GIRO">Interbank GIRO</option>
					<option value="Credit Card">Credit Card (First premium only)</option>
                    <option value="Cash">Cash</option>
					<option value="Cheque ">Cheque</option>
			</select>
			</div>
			
			 <label for="GIRO_NOTE" class="ui-input-text"><strong>Please attach a completed copy of GIRO form.  First & subsequent premiums Not applicable to monthly. The first instalment must be remitted by cash/cheque. (InsureCo/SCB/DBS/POSB/Maybank/UOB/ payment mode. 
           		For monthly cases, two instalments are required. Citibank Visa/MasterCard only). </strong></label>
				
           
            	<fieldset class="ui-grid-a">
                        <div class="ui-block-a"><button type="reset" data-theme="c">Reset</button></div>
                        <div class="ui-block-c"><a href="#name_of_country_and_city_duration" data-role="button" data-theme="b" data-transition="fade">Next</a></div>
                  	</fieldset>
                  	
                  	</div>
           </div>
           
            <div data-role="page" id="name_of_country_and_city_duration">

                    <div data-role="header">
                    	<h1>Name of Country and City Duration</h1>
                    </div>
					
					<div data-role="content">
						
						<ol type="I" data-role="listview">
							<li style="background:transparent">
							Do you intend to travel outside your current country of residence in the next 12 months?
                        
							  	<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="country_city_q1" id="id_country_city_q1_yes" value="yes"  />
									<label for="id_country_city_q1_yes">Yes</label>
									<input type="radio" name="country_city_q1" id="id_country_city_q1_no" value="no"  />
									<label for="id_country_city_q1_no">No</label>
								</fieldset>
							
 						<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
							<label for="travel_purpose" id="id_travel_purpose_label" class="ui-input-text">Purpose of Travel 
								(Residence / Business / Others, please specify)</label>
							<input type="text" name="travel_purpose" id="id_travel_purpose_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
						</div>
						</li>
						
						<li>
						Do you have any interest in Singapore e.g. family, property, business or others?
                        
					  		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
								<input type="radio" name="country_city_q2" id="id_country_city_q2_yes" value="yes"  />
								<label for="id_country_city_q2_yes">Yes</label>
								<input type="radio" name="country_city_q2" id="id_country_city_q2_no" value="no"  />
								<label for="id_country_city_q2_no">No</label>
							</fieldset>
                        
                        
                  			<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
								<label for="yes_details" id="id_country_city_q2_yes_label" class="ui-input-text">If yes, please provide details below. 
								(Not applicable to Singaporean/SPR):</label>
								<input type="text" name="yes_details" id="id_country_city_q2_yes_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
							</div>  
						</li>
					</ol>    
					
					</div>
					<div data-theme="a" data-role="header" id="second-header">
           				 <h3>
                		Residence & Travel Details of Life to be Assured
					   
            			</h3>
        			</div>            
					
					<ol type="I" data-role="listview">
						<li style="background:transparent">
							For the past 12 months, have you spent any amount of time in various countries? 
							<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
								<input type="radio" name="travel_q1" id="id_travel_q1_yes" value="yes"  />
								<label for="id_travel_q1_yes">Yes</label>
								<input type="radio" name="travel_q1" id="id_travel_q1_no" value="no"  />
								<label for="id_travel_q1_no">No</label>
							</fieldset>     
							
							<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
								<label for="travel_purpose" id="id_travel_purpose_12mth_label"class="ui-input-text">Purpose of Travel 
									(Residence / Business / Others, please specify)</label>
								<input type="text" name="travel_purpose" id="id_travel_purpose_12mth_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
							</div>
					              
            
				            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
								<label for="country_name" id="id_name_of_country_label" class="ui-input-text">Name of country And City </label>
								<input type="text" name="country_name" id="id_name_of_country_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
							</div>
							
							<div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
								<label for="stay_duration" id="id_stay_duration_label" class="ui-input-text">Stay Duration</label>
								<input type="text" name="stay_duration" id="id_stay_duration_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
							</div>     
				       
				          </li>  
				          
				           </ol>
				          <div data-role="header">
							<h1>Question No. Details </h1>
							</div>
            
         					<ol type="I" data-role="listview">
								<li style="background:transparent">
								Do you have any medical insurance, personal accident, life or any other insurance policy(ies) with this or any other company? <br />
                        
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 1em 0 0 2em;">
									<input type="radio" name="question_1a" id="id_question_1a_this_company" value="this_company"  />
									<label for="id_question_1a_this_company">This Company</label>
									<input type="radio" name="question_1a" id="id_question_1a_other_company" value="other_company"  />
									<label for="id_question_1a_other_company">Other Company</label>
								</fieldset>
								</li>
				         
								<li style="background:transparent">
								Do you have any application for or reinstatement of your life, critical
								 illness, disability or health insurance policy pending or has itbeen withdrawn, 
								 deferred, declined or accepted at special rates or terms with this or any other office?  <br />
                        
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 1em 0 0 2em;">
									<input type="radio" name="question_1b" id="id_question_1b_yes" value="yes"  />
									<label for="id_question_1b_yes">Yes</label>
									<input type="radio" name="question_1b" id="id_question_1b_no" value="no"  />
									<label for="id_question_1b_no">No</label>
								</fieldset>
								</li>
								
								<li style="background:transparent">
								Are you making or have you made any claims, including hospitalisation claims, 
								on any policy(ies) with this or any other office? If yes, please give full details.   <br />
                        
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 1em 0 0 2em;">
									<input type="radio" name="question_1c" id="id_question_1c_yes" value="yes"  />
									<label for="id_question_1c_yes">Yes</label>
										
									<input type="radio" name="question_1c" id="id_question_1c_no" value="no"  />
									<label for="id_question_1c_no">No</label></br>
									<div data-role="fieldcontain"  class="ui-field-contain ui -body ui-br">
											<label id="id_question_1c_give_details_label"> If yes, please give full details.</label>
											<textarea cols="40" rows="8" name="textarea" id="id_question_1c_give_details_ta"></textarea>
										</div>
								</fieldset>
								</li>
								
								<li style="background:transparent">
								Is this proposal to replace or intended to replace any policy(ies) with this or any other office?
								Warning - It is usually disadvantageous to replace an existing insurance policy with a new one.<br />
                        
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 1em 0 0 2em;">
									<input type="radio" name="questio_1d" id="id_questio_1d_yes" value="yes"  />
									<label for="id_questio_1d_yes">Yes</label>
									<input type="radio" name="questio_1d" id="id_questio_1d_no" value="no"  />
									<label for="id_questio_1d_no">No</label>
								</fieldset>
								</li>
				         </ol>
				         
				          <div data-role="header">
							<h1>General & Health Details of Life to be Assured</h1>
							</div>
            
         					<ol type="I" data-role="listview">
								<li style="background:transparent">
								Are you currently engaged in or have you any intention of engaging in: </br>
                        
                        
                                   Military or private flying other than as a passenger travelling solely for transport? 
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="questio_6a" id="id_questio_6a_yes" value="yes"  />
									<label for="id_questio_6a_yes">Yes</label>
									<input type="radio" name="questio_6a" id="id_questio_6a_no" value="no"  />
									<label for="id_questio_6a_no">No</label>
								</fieldset>
                        
            					</br>
	           					
		                                  Hazardous pursuits such as scuba diving, mountain/rock climbing, free fall parachuting, sky diving, motor racing etc?
								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="questio_6b" id="id_questio_6b_yes" value="yes"  />
									<label for="id_questio_6b_yes">Yes</label>
									<input type="radio" name="questio_6a" id="id_questio_6b_no" value="no"  />
									<label for="id_questio_6b_no">No</label>
								</fieldset>
								
								<li style="background:transparent">
										Do you consume beer, wine or alcohol?
	  								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="questio_7" id="id_questio_7_yes" value="yes"  />
										<label for="id_questio_7_yes">Yes</label>
										<input type="radio" name="questio_7" id="id_questio_7_no" value="no"  />
										<label for="id_questio_7_no">No</label>
									</fieldset>
								</li>
								
								<li style="background:transparent">
									Have you ever taken narcotics, any habit forming drugs or have you ever been treated for drug or alcohol addiction? 
			 					 <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="questio_8" id="id_questio_8_yes" value="yes"  />
									<label for="id_questio_8_yes">Yes</label>
									<input type="radio" name="questio_8" id="id_questio_8_no" value="no"  />
									<label for="id_questio_8_no">No</label>
								</fieldset>           
								</li>
								
								<li style="background:transparent">
									Have you consulted any doctor(s) in the last three years? 
									<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="question_9" id="id_question_9_yes" value="yes"  />
										<label for="id_question_9_yes">Yes</label>
										<input type="radio" name="question_9" id="id_question_9_no" value="no"  />
										<label for="id_question_9_no">No</label>
									</fieldset>           
                        
       							 <label for="details_1" class="ui-input-text" id="id_question_9_details_1_if_yes_label"></strong>If yes to above questions, please provide details below.</strong> </label>
					                </br>
					                
					                <label for="details_1" class="ui-input-text" id="id_question_9_details_1_label">Purpose, destination, frequency and length of each stay </label>
									<input type="text" name="details_1" id="id_question_9_details_1_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
							
								
					                <label for="details_2" class="ui-input-text" id="id_question_9_details_2_label">Name of country / City, duration, purpose of travel </label>
									<input type="text" name="details_2" id="id_question_9_details_2_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
								 

									<label for="details_3" class="ui-input-text" id="id_question_9_details_3_label">Specify activity</label>
									<input type="text" name="details_3" id="id_question_9_details_3_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
								
									<label for="details_4" class="ui-input-text" id="id_question_9_details_4_label">When, type, quantity consumed and frequency of consumption per week </label>
									<input type="text" name="details_4" id="id_question_9_details_4_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
									
								    <label for="details_5" class="ui-input-text" id="id_question_9_details_5_label">Name and address of doctor and reason/date for consultation</label>
									<input type="text" name="details_5" id="id_question_9_details_5_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
								                   
								 </li>
								             
								 
								    <h4>you ever had or been told to have or been treated for:</h4> <br />
								    
    
									    <ol type="I" data-role="listview">
									    <li>
											Epilepsy, fits, stroke, paralysis, weakness of limb, prolonged headache, unconsciousness, nervous breakdown, depression orany other nervous/mental disorders?
												<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
												<input type="radio" name="questio_10a" id="id_questio_10a_yes" value="yes"  />
												<label for="id_questio_10a_yes">Yes</label>
												<input type="radio" name="questio_10a" id="id_questio_10a_no" value="no"  />
												<label for="id_questio_10a_no">No</label>
												</fieldset>
									</li>
									
									<li>
										Diabetes, thyroid disorders or any other endocrine disorders? 
		    
							    		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
											<input type="radio" name="question_10b" id="id_question_10b_yes" value="yes"  />
											<label for="id_question_10b_yes">Yes</label>
											<input type="radio" name="questio_10b" id="id_question_10b_no" value="no"  />
											<label for="id_question_10b_no">No</label>
										</fieldset>
					            	</li>
    
    
								    <li>
										 Ear discharge, nose bleeds, double vision, impaired sight, hearing or speech or any other disorders of ear, eye, nose or throat?  
								    
				   						 <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
											<input type="radio" name="question_10c" id="id_question_10c_yes" value="yes"  />
											<label for="id_question_10c_yes">Yes</label>
											<input type="radio" name="questio_10c" id="id_question_10c_no" value="no"  />
											<label for="id_question_10c_no">No</label>
										</fieldset>
            
            						</li>
    
								     <li>
										 Asthma, bronchitis, persistent cough, coughing with blood, pneumonia, tuberculosis, chest or breathing complaints/discomfortor any other lung disorders?  
								    
							    		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
											<input type="radio" name="questio_10d" id="id_questio_10d_yes" value="yes"  />
											<label for="id_questio_10d_yes">Yes</label>
											<input type="radio" name="questio_10d" id="id_questio_10d_no" value="no"  />
											<label for="id_questio_10d_no">No</label>
										</fieldset>
									</li>
    
								    <li>
										  Raised cholesterol, high blood pressure, heart attack, heart murmur, mitral valve prolapse or other heart valve disorders, breathlessness,
								irregular or fast heart rate, chest discomfort or pain, diseases of or any other disorders of the heart or blood vessels?  
								    
					   			 <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="question_10e" id="id_question_10e_yes" value="yes"  />
									<label for="id_question_10e_yes">Yes</label>
									<input type="radio" name="question_10e" id="id_question_10e_no" value="no"  />
									<label for="id_question_10e_no">No</label>
								</fieldset>
            
           						 </li>
           						 
           						 <li>
		 							Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel disorders? 
    
			   						<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="question_10f" id="id_question_10f_yes" value="yes"  />
										<label for="id_question_10f_yes">Yes</label>
										<input type="radio" name="question_10f" id="id_question_10f_no" value="no"  />
										<label for="id_question_10f_no">No</label>
									</fieldset>
			            		</li>
							     <li>
									 Jaundice, Hepatitis B carrier or any form of hepatitis, liver disorders or gall bladder disorders? 

    
					    		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
									<input type="radio" name="question_10g" id="id_question_10g_yes" value="yes"  />
									<label for="id_question_10g_yes">Yes</label>
									<input type="radio" name="question_10g" id="id_question_10g_no" value="no"  />
									<label for="id_question_10g_no">No</label>
								</fieldset>
					            
           					 </li>
    
						     <li>
								 Blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladder or genital organs, includingurinary incontinence?

    
    						<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
								<input type="radio" name="question_10h" id="id_question_10h_yes" value="yes"  />
								<label for="id_question_10h_yes">Yes</label>
								<input type="radio" name="question_10h" id="id_question_10h_no" value="no"  />
								<label for="id_question_10h_no">No</label>
							</fieldset>
            			</li>
            			
					    <li>
							 Slipped disc, gout, arthritis, osteoporosis (weak bones), fractured bones, pain or deformity or disorders of the muscles, bones,
					spine, limbs or joints or severe injury(ies)? 

    				<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
						<input type="radio" name="question_10i" id="id_question_10i_yes" value="yes"  />
						<label for="id_question_10i_yes">Yes</label>
						<input type="radio" name="question_10i" id="id_question_10i_no" value="no"  />
						<label for="id_question_10i_no">No</label>
					</fieldset>
            </li>
    
		    <li>
				 Cancer, tumours, cysts or growths of any kind?

    
    		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
				<input type="radio" name="question_10j" id="id_question_10j_yes" value="yes"  />
				<label for="id_question_10j_yes">Yes</label>
				<input type="radio" name="questio_10j" id="id_question_10j_no" value="no"  />
				<label for="id_question_10j_no">No</label>
			</fieldset>
            
           </li>
           
	       <li>
			Anaemia, any other disorders of the blood, advised to abstain from donating or received blood transfusion or blood products onaccount of haemophilia or any other reason? 
	    
    		<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
				<input type="radio" name="question_10k" id="id_question_10k_yes" value="yes"  />
				<label for="id_question_10k_yes">Yes</label>
				<input type="radio" name="questio_10k" id="id_question_10k_no" value="no"  />
				<label for="id_question_10k_no">No</label>
			</fieldset>
            
            </li>
            
		     <li>
				Systemic Lupus Erythematosus, rheumatic fever, rheumatoid arthritis, kawasaki disease or any other disorders of the immunesystem?
		    
	   		 <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
				<input type="radio" name="question_10l" id="id_question_10l_yes" value="yes"  />
				<label for="id_question_10l_yes">Yes</label>
				<input type="radio" name="questio_10l" id="id_question_10l_no" value="no"  />
				<label for="id_question_10l_no">No</label>
			</fieldset>
            
            </li>
	       
	        <li>
				Any other illness, disorder, injury, disability, operation or hospitalisation not mentioned above?
    
    			<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
					<input type="radio" name="question_10m" id="id_question_10m_yes" value="yes"  />
					<label for="id_question_10m_yes">Yes</label>
					<input type="radio" name="question_10m" id="id_question_10m_no" value="no"  />
					<label for="id_question_10m_no">No</label>
				</fieldset>
            </li>
				
		
			
            <li style="background:transparent">
        		In the past 5 years, have you had any tests done such as X-Ray, ultrasound, CT Scan, biopsy, electrocardiogram (ECG), blood orurine test? 
         
						<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
							<input type="radio" name="questio_9" id="id_question_11_yes" value="yes"  />
							<label for="id_question_11_yes">Yes</label>
							<input type="radio" name="question_11" id="id_question_11_no" value="no"  />
							<label for="id_question_11_no">No</label>
						</fieldset>     
             </li>
            
             <li style="background:transparent">
            	Have you or your spouse (if applicable) been told to have, or have received any medical advice, counselling or treatment in connectionwith sexually transmitted disease, AIDS, AIDS Related Complex or any other AIDS related condition? 
            
            	<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
						<input type="radio" name="questio_12" id="id_question_12_yes" value="yes"  />
						<label for="id_question_12_yes">Yes</label>
						<input type="radio" name="question_12" id="id_question_12_no" value="no"  />
						<label for="id_question_12_no">No</label>
				</fieldset>     
            </li>
            
             <li style="background:transparent">
           Have you ever had HIV testing done for purposes other than pregnancy testing, Singapore PR application and SAF overseasmilitary training? 
            
            
            <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
				<input type="radio" name="questio_13" id="id_question_13_yes" value="yes"  />
				<label for="id_question_13_yes">Yes</label>
				<input type="radio" name="question_13" id="id_question_13_no" value="no"  />
				<label for="id_question_13_no">No</label>
			</fieldset>     
            </li>
    
		      <li style="background:transparent">
		          Do you belong, or have ever belonged, to any of the following AIDS high-risk groups established by the health authorities includinghaemophiliacs, intravenous (i.v.) drug users, bisexuals, homosexuals or sexual partners of the preceding groups?
		            
            
            	<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
					<input type="radio" name="question_14" id="id_question_14_yes" value="yes"  />
					<label for="id_question_14_yes">Yes</label>
					<input type="radio" name="question_14" id="id_question_14_no" value="no"  />
					<label for="id_question_14_no">No</label>
				</fieldset>    
                        
                        
                 <label for="No_14_details" id="id_no_14_details" class="ui-input-text">Please indicate the specific high-risk group </label>
				<input type="text" name="No_14_details" id="id_no_14_details_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset"> 
            </li>
    
		    <li style="background:transparent">
		          Have you ever in the last 3 months had any of the following symptoms for more than one week continuously: fatigue, weightloss, diarrhoea, enlarged nodes or unusual skin lesions?
		            
            
            	<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
					<input type="radio" name="question_15" id="id_question_15_yes" value="yes"  />
					<label for="id_question_15_yes">Yes</label>
					<input type="radio" name="question_15" id="id_question_15_no" value="no"  />
					<label for="id_question_15_no">No</label>
				</fieldset> 
                        
                 <label for="14details" class="ui-input-text" id="id_14details_label"><strong>If yes to above 5 questions, please provide details below.</strong></label>
    			<br />   
    
    			<label for="14details" class="ui-input-text" id="id_14details_1_label">Name of condition and date of diagnosis </label>
					<input type="text" name="14details" id="id_14details_1_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
    			<label for="14details_2" class="ui-input-text" id="id_14details_2_label" >Name and address of each doctor/hospital </label>
					<input type="text" name="14details_2" id="id_14details_2_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
    			<label for="14details_3" class="ui-input-text" id="id_14details_3_label">Duration of illness/injury and date of recovery as appropriate  </label>
					<input type="text" name="14details_3" id="id_14details_3_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
    			<label for="14details_4" class="ui-input-text" id="id_14details_4_label">Nature of tests done, dates, results and reason for tests. Copy of the above test(s), if any </label>
					<input type="text" name="14details_4" id="id_14details_4_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
            </li>
            
            <li style="background:transparent">
          		Have either of your natural parents or any siblings died or suffered from cancer, heart disease, stroke, high blood pressure, diabetes, 
				kidney disease, mental disorder, dementia/Alzheimer's disease, Parkinson's Disease, tuberculosis, Down's Syndrome or any hereditary 
				disease? 
            
            
            <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
							<input type="radio" name="question_16" id="id_question_16_yes" value="yes"  />
							<label for="id_question_16_yes">Yes</label>
							<input type="radio" name="question_16" id="id_question_16_no" value="no"  />
							<label for="id_question_16_no">No</label>
						</fieldset> 
                        
                        <label for="16details_2" class="ui-input-text"  id="id_16details_2_label">Relationship Condition  </label>
				<input type="text" name="16details_2" id="id_16details_2_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
    			<label for="16details_3" class="ui-input-text" id="id_16details_3_label" >Cause of death Age at Onset If Deceased  </label>
					<input type="text" name="16details_3" id="id_16details_3_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
    
    			<label for="16details_4" class="ui-input-text" id="id_16details_4_label">Age at Death  </label>
					<input type="text" name="16details_4" id="id_16details_4_tb" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
         		</ol>
       
						
					<fieldset class="ui-grid-a">
                        <div class="ui-block-a"><button type="reset" data-theme="c">Reset</button></div>
                        <div class="ui-block-c"><a href="#health_question_for_female_only" data-role="button" data-theme="b" data-transition="fade">Next</a></div>
                  	</fieldset>
                  	
                  	</div>
                  	
                  	 <div data-role="page" id="health_question_for_female_only">

                    <div data-role="header">
                    	<h1>Health Questions for female only</h1>
                    </div>
                    	
                    	<div data-role="content" >  
		
        					<ol type="I" data-role="listview">
								<li style="background:transparent">
        
	       							Have you ever had an abnormal pap smear result or been told by doctor to have a repeat pap smear within the next six months? 
	       							 <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="questio_17" id="id_question_17_yes" value="yes"  />
										<label for="id_question_17_yes">Yes</label>
										<input type="radio" name="questio_17_q1" id="id_question_17_no" value="no"  />
										<label for="id_question_17_no">No</label>
									</fieldset>
								</li>
								
								<li style="background:transparent">
								       Have you had an abnormal mammogram or been advised to have mammogram, biopsy, operation of the breasts, ultrasound 
										of the pelvis or breasts, cone biopsy or colposcopy, or any other gynaecological investigations?
	       							<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="question_18" id="id_question_18_yes" value="yes"  />
										<label for="id_question_18_yes">Yes</label>
										<input type="radio" name="question_18" id="id_question_18_no" value="no"  />
										<label for="id_question_18_no">No</label>
									</fieldset>
								</li>    
								
								<li style="background:transparent">
								      Have you ever had any disease or disorder of the cervix uteri, uterus, ovaries, vulva or fallopian tubes including ovarian cysts, uterine 
								prolapse, abnormal uterine or vaginal bleeding, abnormal enlargement of the abdomen, fibroid, polyp, carcinoma in situ, cancer 
								or growth? 
       								<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="questio_19" id="id_questio_19_yes" value="yes"  />
										<label for="id_questio_19_yes">Yes</label>
										<input type="radio" name="questio_19" id="id_questio_19_no" value="no"  />
										<label for="id_questio_19_no">No</label>
									</fieldset>
								</li>    
								
								<li style="background:transparent">
							     	Have you ever had any disease or disorder of the breasts including breast lump, cyst, fibroadenoma, fibrocystic disease, nipple 
									changes or discharge, mastitis, mammary dysplasia, Paget's disease of the nipple or breast, carcinoma in situ, cancer or growth? 
        							<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="questio_20" id="id_questio_20_yes" value="yes"  />
										<label for="id_questio_20_yes">Yes</label>
										<input type="radio" name="questio_20" id="id_questio_20_no" value="no"  />
										<label for="id_questio_20_no">No</label>
									</fieldset>
								</li>   
								
								<li style="background:transparent">
								      For females who have conceived or are currently pregnant (if not applicable please indicate? have you had any complications 
									  during pregnancy (e.g. gestational diabetes, hypertension, protein in urine, etc)? 
									  If yes to questions 17 to 21, please provide details below. 
									  Type, reason, date of test done and result of test (copy to be submitted if available) 
        							<fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
										<input type="radio" name="questio_21" id="id_questio_21_yes" value="yes"  />
										<label for="id_questio_21_yes">Yes</label>
										<input type="radio" name="questio_21" id="id_questio_21_no" value="no"  />
										<label for="id_questio_21_no">No</label>
									</fieldset>
								</li>    
								
								<fieldset class="ui-grid-a">
			                        <div class="ui-block-a"><button type="reset" data-theme="c">Reset</button></div>
			                        <div class="ui-block-c"><a href="#insurance_declaration" data-role="button" data-theme="b" data-transition="fade">Next</a></div>
			                  	</fieldset>
                  	
						</div>    
                    
                    </div>
           

                    <div data-role="page" id="insurance_declaration">

                    <div data-role="header">
                    	<h1>Insurance Declaration</h1>
                    </div>

                    <div data-role="content" data-theme="c">

                    <p>
                    I/We understand that for non Singapore-dollar policy, the Singapore-dollar
                    return will depend on prevailing exchange rates which may be highly volatile.
                    InsureCo does not bear the loss resulting from any currency conversion or
                    the cost of charges incurred on any transaction pertaining to currency
                    conversions.
                    </p>

                    <p>
                    This policy may be cancelled by written request to us within 14 days after
                    you receive the policy document in which case premiums less medical fees
                    incurred in assessing the risk under the policy will be refunded. Should
                    InsureCo decline the proposal, then I/we shall be entitled to a full refund of
                    the premium(s) paid.
                    </p>

                    <p>
                    I/We understand and accept that if I/we do not already have a InsureCoAccess
                    PIN, InsureCo will send a InsureCoAccess PIN to me/us at the mailing address
                    specified in this proposal form after the inception of the policy. (InsureCoAccess
                    is InsureCo customer internet portal via our corporate website for
                    policyholders to access their policy information and perform selected policy
                    transactions).
                    </p>

                    <p>
                    I/We understand that if I/we do not hold Singapore citizenship status, it is
                    my/our sole responsibility to ensure that, by completing and submitting this
                    proposal, I/we will not breach or violate any of the applicable local laws and
                    regulations of the jurisdiction of the country of my/our nationality (the
                    "Applicable Local Laws").
                    </p>

                    <p>
                    I/We hereby fully indemnify and hold harmless Insurance Company and its officers, employees and agents against all losses, damages, civil penalties and expenses (including but not limited to legal expenses on a solicitor-client basis) that may be sufferred by any of them in connection
                    with any breach or violation on my/our part of the Applicable Local Laws.
                    All correspondence and documents from Insurance Co to me/us will be considered
                    delivered and received in the ordinary course of the post 7 days after the
                    date of posting to the last known address notified to InsureCo.
                    </p>

                    <p>
                        I/We expressly authorise and consent to InsureCo, its officers, employees
                        and agents disclosing, at their sole discretion, any and all information relating
                        to me/us, including my/our personal particulars, my/our transactions and
                        dealings and my/our policy or policies of insurance with InsureCo, to any
                        of the following persons, whether in Singapore or elsewhere:
                    </p>

                    <ol data-role="listview" data-theme="d">
                        <li>
                            Insure Co&#146;s holding companies, branches, representative offices, subsidiaries,
                            related corporations or affiliates.
                        </li>
                        <li>
                            Any of Insure Co&#146;s contractors or third party service providers or distribution
                            partners or professional advisers or agents.
                        </li>
                        <li>
                            Any regulatory, supervisory or other authority, court of law, tribunal or
                            person, in any jurisdiction, where such disclosure is required by law,
                            regulation, judgement or order of court or order of any tribunal or as a
                            matter of practice.
                        </li>
                        <li>
                            Any actual or potential assignee(s) or transferee(s) of any rights and
                            obligations of InsureCo under or relating to my/our policy or policies for
                            any purpose connected with the proposed assignment or transfer.
                        </li>
                        <li>
                            Any credit bureau, insurer or financial adviser,
                            for such purpose(s) that InsureCo in its reasonable opinion considers
                            appropriate including but not limited to the purposes of underwriting,
                            customer servicing, investigation of InsureCo representatives and monitoring
                            undesirable sales practices.
                        </li>
                    </ol>

                    <p>
                        <b>Please read carefully before signing this proposal.</b>
                    </p>

                    <p>
                        I/We understand that the assurance will not commence until the proposal
                        has been received and officially accepted by InsureCo Assurance Company
                        Singapore (Pte) Limited (Insure Co?, premiums have been paid and an
                        official letter indicating commencement of cover has been issued).
                    </p>

                    <p>
                        I/We declare that the information given in this proposal and any information
                        supplied to InsureCo or to the medical examiner of InsureCo is true and
                        that no material facts (i.e. facts likely to influence the assessment and
                        acceptance of this proposal) have been withheld and to the best of my/our
                        knowledge and belief the information given herein is true and complete and
                        shall be the basis of my/our contract with Insure Co. I/We agree to pay to
                        InsureCo any medical fee incurred by Insure Co under this proposal should.
                    </p>

                    <p>
                        I/we fail to take up the policy within 21 days from the date of InsureCo&#146;s
                        acceptance of the proposal at standard rates.
                        I/We agree and authorise
                    </p>

                    <ol data-role="listview" data-theme="d">
                        <li>
                            Any medical source, insurance office or organisation to release to InsureCo; and
                        </li>
                        <li>
                            InsureCo to release to any medical source or insurance office
                            any relevant information concerning the Life to be Assured at any time,
                            irrespective of whether the proposal is accepted by InsureCo.
                        </li>
                    </ol>

                    <p>
                        I/We agree to inform InsureCo if there is any change in the state of health,
                        occupation or activity of the Life to be Assured between the date of this
                        proposal or medical examination and the issue of my policy. On receiving
                        this information InsureCo is entitled to accept or reject my/our proposal.
                    </p>

                    <p>
                        A photographic copy of this authorisation shall be as valid as the original.
                        I/We confirm that the entire marketing and selling process in respect of
                        my/our proposed insurance application has been conducted in Singapore,
                        which includes but is not limited to the following:
                    </p>

                    <ol data-role="listview" data-theme="d">
                        <li>
                            I/We have received all of the insurance related marketing materials in Singapore;
                        </li>
                        <li>
                            The agent/sales staff has explained the details of my/our proposed insurance plan in Singapore;
                        </li>
                        <li>
                            I/We have signed all the documents in respect of my/our proposed
                            insurance application (including but not limited to the Proposal Form) in
                            Singapore; and
                        </li>
                        <li>
                            I/We have paid the initial premium in respect of my/our proposed insurance application in Singapore.
                        </li>
                    </ol>

                    <p>
                        I/We declare that I/we have received a copy of our Guide to Life
                        Insurance or our Guide to Health Insurance? or both, InsureCo
                        Way Planner (WP?, product Summary? and benefit Illustration?
                        the contents of which had been explained to me/us to my/our
                        satisfaction.
                    </p>

                    <p>
                        I/We further declare that I/we am/are not an undischarged bankrupt
                        and that I/we have committed no act of bankruptcy within the last
                        twelve months and that no receiving order or adjudication in
                        bankruptcy has been made against me/us during that period.
                    </p>

                    <p>
                        I/We understand that the policy applied for herein shall be underwritten
                        as a Singapore policy and be entered in the register of Singapore
                        policies of InsureCo.
                    </p>

                    <fieldset class="ui-grid-a">
                        <div class="ui-block-a">
                            <button type="reset" data-theme="c">
                                Disagree
                            </button>
                        </div>
                        <div class="ui-block-b">
                            <a href="#details_of_credit_card_payment" data-role="button" data-theme="b" data-transition="fade">Agree</a>
                        </div>
                    </fieldset>

                </div>

            </div>

            <div data-role="page" id="details_of_credit_card_payment">

                <div data-role="header">
                    <h1>Details of Credit Card Payment</h1>
                </div>

                <div data-role="content">

                    <form action="" method="post">

                        <div data-role="fieldcontain">
                            <label for="credit_card_type" class="ui-input-text">Credit Card Type:</label>
                            <select name="credit_card_type" id="id_credit_card_type">
                                <option value="visa">Visa</option>
                                <option value="master">Master</option>
                            </select>
                        </div>

                        <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                            <label for="credit_card_number" class="ui-input-text">Credit Card Number:</label>
                            <input type="text" name="credit_card_number" id="id_credit_card_number" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                        </div>

                        <label for="cardholder_different_with_proposer" class="ui-input-text"><strong>Is the cardholder differing from proposer?</strong></label>
                        <select name="cardholder_different_with_proposer" id="id_cardholder_different_with_proposer">
                            <option value="blank"></option>
                            <option value="yes">Yes</option>
                            <option value="no">No</option>
                        </select>

                        <div id="id_card_holder_details">

                            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                                <label for="card_holder_name" class="ui-input-text">Card Holder Name:</label>
                                <input type="text" name="card_holder_name" id="id_card_holder_name" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            </div>

                            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                                <label for="relationship_to_cardholder" class="ui-input-text">Relationship To Cardholder:</label>
                                <input type="text" name="relationship_to_cardholder" id="id_relationship_to_cardholder" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            </div>

                            <div data-role="fieldcontain" class="ui-field-contain ui -body ui-br">
                                <label for="first_premium_amount" class="ui-input-text">First Premium Amount:</label>
                                <input type="text" name="first_premium_amount" id="id_first_premium_amount" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                            </div>

                            <div data-role="fieldcontain">
                                <fieldset data-role="controlgroup" data-type="horizontal">
                                    <legend>
                                        Card Expiry Date:
                                    </legend>

                                    <select name="card_expiry_date_year" id="id_card_expiry_date_year">
                                        <option>Year</option>
                                        <option value="2013">2013</option>
                                        <option value="2014">2014</option>
                                    </select>

                                    <select name="card_expiry_date_month" id="id_card_expiry_date_month">
                                        <option>Month</option>
                                        <option value="jan">January</option>
                                        <option value="jul">July</option>
                                        <option value="nov">November</option>
                                    </select>

                                </fieldset>
                            </div>

                        </div>

                       

                        <fieldset class="ui-grid-a">
                            <div class="ui-block-a">
                                <button type="reset" data-theme="c">
                                    Reset
                                </button>
                            </div>
                            <div class="ui-block-b">
                                <a href="#important_notes" data-role="button" data-theme="b" data-transition="fade">Next</a>
                            </div>
                        </fieldset>

                    <!--</form>-->

                </div>

            </div>

            <div data-role="page" id="important_notes">

                <div data-role="header">
                    <h1>Important Notes</h1>
                </div>

                <div data-role="content">
                    <ol type="A" data-role="listview" data-theme="c">
                        <li>
                            By completing this section, the proposer/Cardholder is instructing InsureCo and authorising the Bank to automatically debit his/her Credit Card account for first/renewal/one-time premium amount(s) as indicated to pay for his/her policy or the Cardholder Family Member policy. Family Members? Shall mean spouse, children, parents, parents-in-law, brothers and sisters.
                        </li>
                        <li>
                            The proposer/Cardholder hereby authorises InsureCo to:
                        </li>

                        <ol type="I">
                            <li>
                                Charge an amount different from that stated in this form, arising from a change of the amount that is required to be paid as premium (including but not limited to backdated premiums and an increase in premium due to a change in sum assured or if special terms and conditions apply to your proposal for life assurance); and
                            </li>
                            <li>
                                Correct an error in the expiry date of the credit card, so long as there is no change in the name of the cardholder and the credit card number.
                            </li>
                        </ol>

                        <li>
                            Upon the approval of the proposer and/or the Cardholder application, the premium amount will be charged to the proposer or the Cardholder Credit Card and his/her Credit Card statement will show the amount deducted. No official receipts will be issued. The relevant entries in his/her Credit Card statement will be recognised as evidence of his/her payment.
                        </li>
                        <li>
                            The proposer/cardholder hereby authorise the Bank to notify InsureCo of any change in his/her Credit Card account details. In the event that any new Credit Card account is issued to the proposer/Cardholder in addition to/as replacement of/in lieu of the Credit Card account as indicated in this form, these terms and conditions shall be deemed to apply to each such new Credit Card account and the proposer/Cardholder hereby irrevocably authorize the Bank and InsureCo to debit any of his/her Credit Card accounts from the said Bank for the payment of all permitted regular premiums in relation to the policies indicated herein.
                        </li>
                        <li>
                            Premiums that are charged to the proposer/Cardholder Credit Card exceeding its credit limit available at the time of debit will be rejected. The proposer/Cardholder shall ensure that his/her credit limit is sufficient for the deduction.
                        </li>
                        <li>
                            For premiums paid through this authorisation, the premiums will be reversed to the Credit Card if subsequently the policy transactions are not taken up.
                        </li>
                        <li>
                            If Credit Card is opted for payment of subsequent premiums using InsureCo/SCB/DBS/POSB/Maybank/UOB/Citibank Visa/MasterCard, the premium amount will be charged to the proposer or Cardholder Credit Card on the premium due date.
                        </li>
                        <li>
                            This Credit Card authorisation will remain in force until terminated by the proposer or Cardholder.
                        </li>
                        <li>
                            If the Cardholder is not the owner of the policy, he/she has no right under the Contract (Rights of Third Parties) Act, Cap 53B, to enforce any of the terms and conditions of that policy.
                        </li>
                        <li>
                            Payments by non-Singapore issued Credit Cards are not encouraged for First Premium payment(s). However, if the proposer/cardholder has instructed InsureCo to debit from his/her Non-Singapore issued Credit Card account, the proposer/Cardholder will need to bear all charges (adminstration fees, foreign exchange charges, etc) imposed by the issuing bank. Payments by non-Singapore issued Credit Cards will not be accepted for renewal/one-time premium payments.
                        </li>
                        <li>
                            Each of the specific authorizations set out above shall be in addition to any other consent and/or disclosure that the proposer/Cardholder may have provided to InsureCo and the Bank.
                        </li>
                    </ol>

                    <p>
                        If a material fact is not disclosed in this proposal, any policy issued may not be valid. If you are in doubt as to whether a fact is material, you are advised to disclose it. This includes any information that you may have provided to the Financial Consultant but was not included in the proposal. Please check to ensure you are fully satisfied with the information declared in this proposal.
                    </p>

                    <p>
                        <b>InsureCo Assurance Company Singapore (Pte) Limited
                        <br>
                        </b>
                        Address: 30th Street #30-01 InsureCo Tower Singapore 049712
                        <br>
                        Website: www.InsureCo.com.sg
                        <br>
                        Part of InsureCo plc (United Kingdom)
                        <br>
                    </p>
                </div>

                <fieldset class="ui-grid-a">
                    <div class="ui-block-a">
                        <button type="reset" data-theme="c">
                            Disagree
                        </button>
                    </div>
                    <div class="ui-block-b">
                        <a href="#id_financial_consultant" data-role="button" data-theme="b" data-transition="fade">Agree</a>
                    </div>
                </fieldset>

            </div>

            <div data-role="page" id="id_financial_consultant">

                <div data-role="header">
                    <h1>Financial Consultant</h1>
                </div>

                <div data-role="content">

                    <form action="" method="post">

                        <label for="financial_consultant_instruction" class="ui-input-text"> <strong>Please select the correct answer where applicable and provide the relevant details:</strong> </label>

                        <div data-role="fieldcontain">
                            <ol type="I" data-role="listview">
                                <li style="background:transparent">
                                    Is there any concurrent new proposal application?
                                    <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
                                        <input type="radio" name="financial_consultant_q1" id="id_financial_consultant_q1_yes" value="yes"  />
                                        <label for="id_financial_consultant_q1_yes">Yes</label>
                                        <input type="radio" name="financial_consultant_q1" id="id_financial_consultant_q1_no" value="no"  />
                                        <label for="id_financial_consultant_q1_no">No</label>
                                    </fieldset>
                                </li>
                                <li style="background:transparent">
                                    Does this proposal qualify for any campaign or discount program by InsureCo?
                                    <span id="id_financial_consultant_q2_span">
                                        <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
                                            <input type="radio" name="financial_consultant_q2" id="id_financial_consultant_q2_yes" value="yes"  />
                                            <label for="id_financial_consultant_q2_yes">Yes</label>
                                            <input type="radio" name="financial_consultant_q2" id="id_financial_consultant_q2_no" value="no"  />
                                            <label for="id_financial_consultant_q2_no">No</label>
                                        </fieldset> </span>
                                    <div id="id_campaign_type_division" data-role="fieldcontain" style="padding:0.5em 0 0 0;margin:0;" class="ui-screen-hidden">
                                        <label for="campaign_type" style="font-weight:normal; padding: 0 1em 0 1em;">Campaign Type:</label>
                                        <input type="text" name="campaign_type" id="id_campaign_type" value class="ui-input-text ui-body-c ui-corner-all ui-shadow-inset">
                                    </div>
                                </li>
                                <li style="background:transparent">
                                    Are there any other additional information that you wish to inform InsureCo acout this proposal?
                                    <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
                                        <input type="radio" name="financial_consultant_q3" id="id_financial_consultant_q3_yes" value="yes"  />
                                        <label for="id_financial_consultant_q3_yes">Yes</label>
                                        <input type="radio" name="financial_consultant_q3" id="id_financial_consultant_q3_no" value="no"  />
                                        <label for="id_financial_consultant_q3_no">No</label>
                                    </fieldset>
                                </li>
                                <li style="background:transparent">
                                    Is there any accompanying Advance Premium Deposit Application for this proposal?
                                    <fieldset data-role="controlgroup" data-type="horizontal" style="padding: 0.5em 0 0 1em;">
                                        <input type="radio" name="financial_consultant_q4" id="id_financial_consultant_q4_yes" value="yes"  />
                                        <label for="id_financial_consultant_q4_yes">Yes</label>
                                        <input type="radio" name="financial_consultant_q4" id="id_financial_consultant_q4_no" value="no"  />
                                        <label for="id_financial_consultant_q4_no">No</label>
                                    </fieldset>
                                </li>
                            </ol>
                        </div>

                        <label for="financial_consultant_warning" class="ui-input-text"><strong>Warning:</strong></label>
                        <label for="financial_consultant_warning_content" class="ui-input-text"> PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT (CAP 142), YOU ARE TO DISCLOSE IN THIS PROPOSAL FORM FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE YOU MAY RECEIVE NOTHING FROM THE POLICY. </label>

                        <fieldset class="ui-grid-a">
                            <div class="ui-block-a">
                                <button type="reset" data-theme="c">
                                    Reset
                                </button>
                            </div>
                            <div class="ui-block-b">
                                <a href="#" data-role="button" data-theme="b" data-transition="fade">Next</a>
                            </div>
                        </fieldset>

                    </form>

                </div>

            </div>

			<div data-role="page" id="application_result_page">

				<div data-role="header">
					<h1>Loan Application Result</h1>
				</div>

				<div data-role="content">
					<?php
					if (isset($_SESSION['application_result']) AND $_SESSION['application_result'] == "accepted") {echo "Congratulation, your loan application has approved !";
					} elseif (isset($_SESSION['application_result']) AND $_SESSION['application_result'] == "rejected") {echo "I'm sorry, your loan application has rejected";
					} elseif (isset($_SESSION['application_result']) AND $_SESSION['application_result'] == "review") {echo "Your application is being review, we would get back to your agent as soon as possible. Thank you!";
					} else {echo "error";
					}
					?>
				</div>

			</div>

    </body>
</html>